Provider Demographics
NPI:1356488761
Name:MILLS, MARK A (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:MILLS
Suffix:
Gender:M
Credentials:PA
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 9247
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-9247
Mailing Address - Country:US
Mailing Address - Phone:706-322-7884
Mailing Address - Fax:706-243-2027
Practice Address - Street 1:3465 MACON RD
Practice Address - Street 2:STE D
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-2582
Practice Address - Country:US
Practice Address - Phone:706-243-3051
Practice Address - Fax:706-243-2027
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA174759447AMedicaid
GA100001639CMedicaid
GA970009967OtherRAIL ROAD MEDICARE
GA202I975249OtherMEDICARE PTAN
GA202I975249OtherMEDICARE PTAN
GAS44722Medicare UPIN