Provider Demographics
NPI:1659324739
Name:MILLIS, MICHAEL A (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:MILLIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 WOODROW WILSON RAY CIR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-2061
Mailing Address - Country:US
Mailing Address - Phone:940-683-2297
Mailing Address - Fax:940-683-2984
Practice Address - Street 1:808 WOODROW WILSON RAY CIR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2061
Practice Address - Country:US
Practice Address - Phone:940-683-2297
Practice Address - Fax:940-683-2984
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01542363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82N638Medicare ID - Type Unspecified
TXS78971Medicare UPIN