Provider Demographics
NPI:1225083066
Name:MCMILLAN, IAN S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:S
Last Name:MCMILLAN
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 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:770-496-5555
Mailing Address - Fax:770-939-2887
Practice Address - Street 1:2712 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2512
Practice Address - Country:US
Practice Address - Phone:770-496-5555
Practice Address - Fax:770-939-2887
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4760363AM0700X
GA004760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA153442161KMedicaid
GAQ69451Medicare UPIN
GA153442161KMedicaid