Basic Information
| Provider Information | |||||||||
| NPI: | 1366755993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYCAN | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 COLLIER RD NW | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046052800 | ||||||||
| FaxNumber: | 4043515983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE ROAD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046052800 | ||||||||
| FaxNumber: | 4043515983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2010 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 005811 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 005811 | 01 | GA | GA LICENSE | OTHER |