Individual
MICAH HENDERSON LANCASTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1111 GLYNCO PKWY, BUILDING 1, SUITE 20, BRUNSWICK, GA 31525-7921
(912) 262-1801
(912) 264-6262
Mailing address
2400 BELLEVUE RD, SUITE 21-A, DUBLIN, GA 31021-2885
(478) 275-7202
(478) 274-8418
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
006295
GA
363AM0700X
Medical Physician Assistant
—
—
363AS0400X
Surgical Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003116432
—
GA
05
—
003116443
—
GA
01
—
006295
GEORGIA LICENSE
GA
Enumeration date
09/23/2011
Last updated
03/12/2015
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