Provider Demographics
NPI:1487674156
Name:BLANTON, MICAHEL S (AA)
Entity Type:Individual
Prefix:MR
First Name:MICAHEL
Middle Name:S
Last Name:BLANTON
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1968 PEACHTREE ROAD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-351-1754
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00638363A00000X
GA000638367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000412156Medicaid
GA455538491EMedicaid
432CBJA36Medicare PIN
R12303Medicare UPIN
GA000412156Medicaid