Individual
UI AN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1670 CLAIRMONT RD, DECATUR, GA 30033-4004
(404) 321-6111
Mailing address
PO BOX 134, TYRONE, GA 30290-0134
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
8962
GA
Other
Enumeration date
12/05/2018
Last updated
06/01/2021
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