Provider Demographics
NPI:1902491798
Name:MCDANIEL, MICHAEL RUBEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RUBEN
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4264 JACKSON TRACE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:AL
Mailing Address - Zip Code:35096-6893
Mailing Address - Country:US
Mailing Address - Phone:256-630-3492
Mailing Address - Fax:
Practice Address - Street 1:275 COLLIER RD NW STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1740
Practice Address - Country:US
Practice Address - Phone:404-350-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1181534207RP1001X
1181534363AM0700X, 363AS0400X
GA10321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical