Provider Demographics
NPI:1053997999
Name:MICKOWSKI, THOMAS (CRNP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:MICKOWSKI
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1885
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0885
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:511 PIERCE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5731
Practice Address - Country:US
Practice Address - Phone:570-243-3300
Practice Address - Fax:570-338-3993
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022412363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily