Basic Information
| Provider Information | |||||||||
| NPI: | 1710326459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITHERSPOON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18167 US HWY. 19 N #650 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33764 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1255 HWY 54 W | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707935000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2013 | ||||||||
| LastUpdateDate: | 09/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6837 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.