Provider Demographics
NPI:1609883016
Name:MILLIKIN, CLARENCE THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:THOMAS
Last Name:MILLIKIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:111 ROYAL BURGESS WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4283
Mailing Address - Country:US
Mailing Address - Phone:404-352-4500
Mailing Address - Fax:404-350-0722
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1610
Practice Address - Country:US
Practice Address - Phone:404-352-4500
Practice Address - Fax:404-350-0722
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002525363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002525OtherLICENSE