Healthcare Provider Details

I. General information

NPI: 1104586098
Provider Name (Legal Business Name): MICHAEL MILLICAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 CONNECTICUT AVE NW STE 1250
WASHINGTON DC
20036-1728
US

IV. Provider business mailing address

145 LAKE PARK CT
SHARPSBURG GA
30277-2164
US

V. Phone/Fax

Practice location:
  • Phone: 888-663-6331
  • Fax: 415-272-7176
Mailing address:
  • Phone: 770-362-2569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200002358
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10856
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: