Provider Demographics
NPI:1063403541
Name:MITCHELL, MICHAEL WILEY (CST,CFA,CSA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILEY
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:CST,CFA,CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 E CHEROKEE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2015
Mailing Address - Country:US
Mailing Address - Phone:770-704-9730
Mailing Address - Fax:
Practice Address - Street 1:2521 E CHEROKEE DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2015
Practice Address - Country:US
Practice Address - Phone:770-704-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
GA2229246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical