Provider Demographics
NPI:1336967736
Name:LANDRUM, MICAIAH
Entity type:Individual
Prefix:MR
First Name:MICAIAH
Middle Name:
Last Name:LANDRUM
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 1:81 BIRMINGHAM CIR
Mailing Address - Street 2:
Mailing Address - City:MANQUIN
Mailing Address - State:VA
Mailing Address - Zip Code:23106-3415
Mailing Address - Country:US
Mailing Address - Phone:804-572-1760
Mailing Address - Fax:
Practice Address - Street 1:81 BIRMINGHAM CIR
Practice Address - Street 2:
Practice Address - City:MANQUIN
Practice Address - State:VA
Practice Address - Zip Code:23106-3415
Practice Address - Country:US
Practice Address - Phone:804-572-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110010722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program