Individual
MISTY NICOLE BANKNELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
230 N JEFFERSON ST NE, MILLEDGEVILLE, GA 31061-3418
(478) 453-8484
(478) 452-0987
Mailing address
2400 BELLEVUE RD STE 21A, DUBLIN, GA 31021-2890
(478) 275-7202
(478) 274-8418
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
005333
GA
363AM0700X
Medical Physician Assistant
005333
GA
363AS0400X
Surgical Physician Assistant
005333
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
005333
STATE LICENSE
GA
01
—
P00644516
RR MEDICARE PIN
—
Enumeration date
05/29/2008
Last updated
03/11/2015
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