Provider Demographics
NPI:1962404541
Name:CHAMMOUN, MICHAEL STEPHEN (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:CHAMMOUN
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2310 N PATTERSON ST
Mailing Address - Street 2:BLDG D
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2568
Mailing Address - Country:US
Mailing Address - Phone:229-247-2482
Mailing Address - Fax:229-247-0827
Practice Address - Street 1:2310 N PATTERSON ST
Practice Address - Street 2:BLDG D
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2568
Practice Address - Country:US
Practice Address - Phone:229-247-2482
Practice Address - Fax:229-247-0827
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2010-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA003153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000805AMedicaid
GA100000805AMedicaid
P01260Medicare UPIN