Provider Demographics
NPI:1114365459
Name:BURTON, MICHAEL LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:BURTON
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:PO BOX 102321
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2321
Mailing Address - Country:US
Mailing Address - Phone:770-801-2500
Mailing Address - Fax:770-803-2121
Practice Address - Street 1:400 TOWER ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-514-7550
Practice Address - Fax:770-514-1390
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20297I1312OtherMEDICARE
GA003148046AMedicaid