Provider Demographics
NPI:1477437077
Name:LA VITA KAESS, MIKAELA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:LA VITA KAESS
Suffix:
Gender:X
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 W UNION HILLS DR APT 1089
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1733
Mailing Address - Country:US
Mailing Address - Phone:302-561-1099
Mailing Address - Fax:
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant