Individual
RANDY J MICKELSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
407 S MAIN ST, VIROQUA, WI 54665-2100
(608) 637-3195
Mailing address
1836 SOUTH AVE, LA CROSSE, WI 54601-5429
(608) 782-7300
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
528
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42920800
—
WI
Enumeration date
06/13/2005
Last updated
03/23/2016
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