Provider Demographics
NPI:1609439983
Name:MICKELSON, HANNAH (PA)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:16770 SW EDY RD STE 102
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9679
Practice Address - Country:US
Practice Address - Phone:503-216-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4651363AM0700X
ORPA214103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical