Provider Demographics
NPI:1861115313
Name:MICCICHI, LONDON JUDITH (PA-C)
Entity type:Individual
Prefix:
First Name:LONDON
Middle Name:JUDITH
Last Name:MICCICHI
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:
Practice Address - Street 1:180 WINGO WAY STE 207
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1811
Practice Address - Country:US
Practice Address - Phone:843-884-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5930PAMedicaid