Provider Demographics
NPI:1790909414
Name:PAGE, MICHAEL BRADY (PA-S)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRADY
Last Name:PAGE
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 HIGHWAY 30 WEST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE
Mailing Address - State:MS
Mailing Address - Zip Code:38650
Mailing Address - Country:US
Mailing Address - Phone:662-534-4451
Mailing Address - Fax:
Practice Address - Street 1:206 OXFORD RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3115
Practice Address - Country:US
Practice Address - Phone:662-534-2227
Practice Address - Fax:662-534-2330
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant