Provider Demographics
NPI:1265491179
Name:CARMICHAEL, DORNER LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:DORNER
Middle Name:LEE
Last Name:CARMICHAEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DORNER
Other - Middle Name:LEE
Other - Last Name:TICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:598 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3357
Mailing Address - Country:US
Mailing Address - Phone:478-633-6706
Mailing Address - Fax:478-633-5384
Practice Address - Street 1:764 PINE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2107
Practice Address - Country:US
Practice Address - Phone:478-633-1696
Practice Address - Fax:478-633-2316
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA970011438OtherRAIL ROAD MEDICARE
GA100001881AMedicaid
GA100001881AMedicaid
GA100001881AMedicaid
GAMC1021764OtherDEA