Provider Demographics
NPI:1871640185
Name:HICKEY, MICHAEL (AA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HICKEY
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 ASHLEIGH LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6169
Mailing Address - Country:US
Mailing Address - Phone:678-867-6753
Mailing Address - Fax:
Practice Address - Street 1:2771 ASHLEIGH LN
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-6169
Practice Address - Country:US
Practice Address - Phone:678-867-6753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004432367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA256304030AMedicaid
GA256304030AMedicaid