Provider Demographics
NPI:1356777205
Name:MCMILLAN, MANDY CARTER (PA-C)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:CARTER
Last Name:MCMILLAN
Suffix:
Gender:F
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 1:907 18TH ST E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:
Practice Address - Street 1:416 E MCPHERSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-2276
Practice Address - Country:US
Practice Address - Phone:229-686-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant