Provider Demographics
NPI:1538839246
Name:MICKELSEN, SEAN (PA-C)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:MICKELSEN
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 1:3851 KATELLA AVE STE 255
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3353
Mailing Address - Country:US
Mailing Address - Phone:562-732-4578
Mailing Address - Fax:
Practice Address - Street 1:3851 KATELLA AVE STE 255
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3353
Practice Address - Country:US
Practice Address - Phone:562-732-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant