Provider Demographics
NPI:1073732426
Name:CLARDY, MICHELLE KING (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:KING
Last Name:CLARDY
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 1:900 TOWNE LAKE PKWY
Mailing Address - Street 2:STE 404
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-1602
Mailing Address - Country:US
Mailing Address - Phone:770-926-9229
Mailing Address - Fax:678-415-2164
Practice Address - Street 1:900 TOWNE LAKE PKWY
Practice Address - Street 2:STE 404
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-1602
Practice Address - Country:US
Practice Address - Phone:770-926-9229
Practice Address - Fax:678-415-2164
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003151291FMedicaid
GA003151291HMedicaid
GA003151291FMedicaid