Provider Demographics
NPI:1932327996
Name:MCDANIEL, MICHAEL DAVID (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4245 ANDERSON CIR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4211
Mailing Address - Country:US
Mailing Address - Phone:706-394-4998
Mailing Address - Fax:
Practice Address - Street 1:315 FLUKER ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2108
Practice Address - Country:US
Practice Address - Phone:706-595-1090
Practice Address - Fax:706-595-6010
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant