Basic Information
| Provider Information | |||||||||
| NPI: | 1356777205 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCMILLAN | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | CARTER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 416 E MCPHERSON AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NASHVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316392276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2296862093 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 006991 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.