Provider Demographics
NPI:1447844477
Name:POOLE, MICAH
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:POOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 PHILADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-9136
Mailing Address - Country:US
Mailing Address - Phone:318-452-2988
Mailing Address - Fax:
Practice Address - Street 1:219 PHILADELPHIA RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-9136
Practice Address - Country:US
Practice Address - Phone:318-452-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-20
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA328815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program