Provider Demographics
NPI:1619451150
Name:LILJEGREN, MICHAEL THOMAS (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:LILJEGREN
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 1:6801 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-3709
Mailing Address - Country:US
Mailing Address - Phone:251-633-1100
Mailing Address - Fax:
Practice Address - Street 1:6801 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3709
Practice Address - Country:US
Practice Address - Phone:251-633-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1398363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant