Provider Demographics
NPI:1063967495
Name:MIKESELL, CORA E (PA-C)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:E
Last Name:MIKESELL
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:CORA
Other - Middle Name:
Other - Last Name:CHAMBERLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:299 KINGS DAUGHTERS DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-6514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:299 KINGS DAUGHTERS DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-6514
Practice Address - Country:US
Practice Address - Phone:502-875-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003111A363A00000X
KYPA2122363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300044886Medicaid
KY7100437470Medicaid