Provider Demographics
NPI:1407631096
Name:BLUMHARDT, MYKAILA (PA-C)
Entity type:Individual
Prefix:
First Name:MYKAILA
Middle Name:
Last Name:BLUMHARDT
Suffix:
Gender:F
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 1:1462 CLIFTON RD NE STE 280
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1059
Mailing Address - Country:US
Mailing Address - Phone:404-727-7857
Mailing Address - Fax:
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1063
Practice Address - Country:US
Practice Address - Phone:404-712-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant