Provider Demographics
NPI:1154581528
Name:BOOTH, MICHAEL ANN (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANN
Last Name:BOOTH
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 1:420 E 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3209
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:5764 NEW CALHOUN HWY NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-8252
Practice Address - Country:US
Practice Address - Phone:706-295-4476
Practice Address - Fax:706-295-3018
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002316AMedicaid
GA97WCCTNMedicare PIN