Provider Demographics
NPI:1679784847
Name:KILLIAN, MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:KILLIAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8005 RILLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7622
Mailing Address - Country:US
Mailing Address - Phone:727-215-3594
Mailing Address - Fax:
Practice Address - Street 1:8005 RILLWOOD DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7622
Practice Address - Country:US
Practice Address - Phone:727-215-3594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA-9102087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP96640Medicare UPIN