Provider Demographics
NPI:1215996996
Name:OLIVER, MICHAEL TAYLOR (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TAYLOR
Last Name:OLIVER
Suffix:
Gender:M
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:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-0459
Mailing Address - Country:US
Mailing Address - Phone:706-788-3234
Mailing Address - Fax:
Practice Address - Street 1:396 HISTORIC HIGHWAY 441 N
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4522
Practice Address - Country:US
Practice Address - Phone:706-754-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10063294OtherAMERIGROUP
GA335897OtherWELLCARE
GA100001460AMedicaid
GA10063294OtherAMERIGROUP
GA97BBDTZMedicare ID - Type Unspecified