Provider Demographics
NPI:1245895564
Name:COHEN, MIKAELA RENEE (PA)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:RENEE
Last Name:COHEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1691 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6039
Mailing Address - Country:US
Mailing Address - Phone:831-706-7086
Mailing Address - Fax:
Practice Address - Street 1:416 SPRING ST STE 201
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-3155
Practice Address - Country:US
Practice Address - Phone:805-238-7250
Practice Address - Fax:805-238-0165
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant