Provider Demographics
NPI:1710985049
Name:GRIFFIN, MICHAEL TODD (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:604 N ACADIA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4897
Mailing Address - Country:US
Mailing Address - Phone:985-446-5079
Mailing Address - Fax:985-447-2497
Practice Address - Street 1:100 PHOENIX DR
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510-2396
Practice Address - Country:US
Practice Address - Phone:337-898-3700
Practice Address - Fax:337-898-3702
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LALA10629207Y00000X
LAPA.A10629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q43959Medicare UPIN
LA5CA42P668Medicare ID - Type Unspecified