Provider Demographics
NPI:1033650080
Name:YU, MICAELA R (PA-C)
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:R
Last Name:YU
Suffix:
Gender:
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 1:13502 OAK GROVE CT
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-6601
Mailing Address - Country:US
Mailing Address - Phone:405-695-9580
Mailing Address - Fax:
Practice Address - Street 1:1509 N SHAWNEE AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4163
Practice Address - Country:US
Practice Address - Phone:405-695-9580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK4499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator