Provider Demographics
NPI:1386458271
Name:MIC, PHILIP ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:ROBERT
Last Name:MIC
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 1:6405 FRANCE AVE S STE W200
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2186
Mailing Address - Country:US
Mailing Address - Phone:612-365-5000
Mailing Address - Fax:952-836-3950
Practice Address - Street 1:6405 FRANCE AVE S STE W200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2186
Practice Address - Country:US
Practice Address - Phone:612-365-5000
Practice Address - Fax:952-836-3950
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant