Provider Demographics
NPI:1316467038
Name:MIKSICH, MORGAN DIANE (PA-C)
Entity type:Individual
Prefix:MS
First Name:MORGAN
Middle Name:DIANE
Last Name:MIKSICH
Suffix:
Gender:F
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 1:100 HOSPITAL AVE.
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-371-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058970363AM0700X
PAOA004102363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical