Provider Demographics
NPI:1104586098
Name:MILLICAN, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MILLICAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 LAKE PARK CT
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-2164
Mailing Address - Country:US
Mailing Address - Phone:770-362-2569
Mailing Address - Fax:
Practice Address - Street 1:1825 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6423
Practice Address - Country:US
Practice Address - Phone:770-502-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant