Healthcare Provider Details

I. General information

NPI: 1073805032
Provider Name (Legal Business Name): MICHAEL DAMICO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 HOSPITAL DR
SPRUCE PINE NC
28777-3035
US

IV. Provider business mailing address

18 JESSICA LN
RINGGOLD GA
30736-5585
US

V. Phone/Fax

Practice location:
  • Phone: 772-468-4551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6088
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05785
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: