Provider Demographics
NPI:1649677709
Name:MICHEFF, KENNETH JEREMY (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JEREMY
Last Name:MICHEFF
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:MICHEFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1107 MEMORIAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8668
Mailing Address - Country:US
Mailing Address - Phone:706-277-7311
Mailing Address - Fax:706-272-3512
Practice Address - Street 1:1107 MEMORIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8668
Practice Address - Country:US
Practice Address - Phone:706-277-7311
Practice Address - Fax:706-272-3512
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant