Provider Demographics
NPI:1306352422
Name:MIETUS, NICHOLAS A (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:MIETUS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 SE FRANK PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-3643
Mailing Address - Country:US
Mailing Address - Phone:918-214-8888
Mailing Address - Fax:918-214-8887
Practice Address - Street 1:309 SE FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-3643
Practice Address - Country:US
Practice Address - Phone:918-214-8888
Practice Address - Fax:918-214-8887
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X
OK2854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant