Healthcare Provider Details

I. General information

NPI: 1265491179
Provider Name (Legal Business Name): DORNER LEE CARMICHAEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DORNER LEE TICE PA-C

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 PINE ST
MACON GA
31201-2107
US

IV. Provider business mailing address

598 3RD ST
MACON GA
31201-3357
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1696
  • Fax: 478-633-2316
Mailing address:
  • Phone: 478-633-6706
  • Fax: 478-633-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000211
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: