Provider Demographics
NPI:1568567824
Name:MORYKWAS, MICHAEL J (AA-C, MMSC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MORYKWAS
Suffix:
Gender:M
Credentials:AA-C, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 CLIFTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1059
Mailing Address - Country:US
Mailing Address - Phone:404-778-7402
Mailing Address - Fax:404-778-4819
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1059
Practice Address - Country:US
Practice Address - Phone:404-778-7402
Practice Address - Fax:404-778-4819
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004648367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA703157555CMedicaid
GA703157555CMedicaid