Individual
DOR MORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1220 CAROLINE ST NE # A-230, ATLANTA, GA 30307-2749
(167) 871-0398
Mailing address
1457 MILL GLENN CT, LAWRENCEVILLE, GA 30045-7144
(814) 218-0855
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
12608
GA
Other
Enumeration date
08/27/2024
Last updated
10/06/2024
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