Provider Demographics
NPI:1871549527
Name:MICKELSEN, PATRICK K (DC)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:K
Last Name:MICKELSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 N HWY 89 STE D
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-2824
Mailing Address - Country:US
Mailing Address - Phone:801-782-2947
Mailing Address - Fax:801-782-2948
Practice Address - Street 1:2240 N HWY 89 STE D
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-2824
Practice Address - Country:US
Practice Address - Phone:801-782-2947
Practice Address - Fax:801-782-2948
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6099655-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV09555Medicare UPIN