Individual
MR. TRACY D. MICKELSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CSFA
Contact information
Practice address
3015 E MAGIC VIEW DR, MERIDIAN, ID 83642-3743
(208) 855-2410
(208) 482-5515
Mailing address
3015 E MAGIC VIEW DR, MERIDIAN, ID 83642-3743
(208) 855-2410
(208) 482-5515
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
178692
ID
Other
Enumeration date
01/23/2008
Last updated
12/07/2017
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