Basic Information
| Provider Information | |||||||||
| NPI: | 1417209610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HADLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | COLLINS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 15TH ST STE BI1056 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067213813 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 S HERLONG AVE STE B | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033241950 | ||||||||
| FaxNumber: | 8033241933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2012 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 006576 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 2274 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 006576 | 01 | GA | LICENSE | OTHER |