Provider Demographics
NPI:1285917401
Name:LANCASTER, MICAH HENDERSON (PA-C)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:HENDERSON
Last Name:LANCASTER
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 1:2400 BELLEVUE RD
Mailing Address - Street 2:SUITE 21-A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2885
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:1111 GLYNCO PKWY
Practice Address - Street 2:BUILDING 1, SUITE 20
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7921
Practice Address - Country:US
Practice Address - Phone:912-262-1801
Practice Address - Fax:912-264-6262
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
GA006295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA006295OtherGEORGIA LICENSE
GA003116432Medicaid
GA003116443Medicaid
GA202I973810Medicare PIN