Individual
BERTA E BOOTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
6572 RIVER PARK DR STE 101, RIVERDALE, GA 30274-2214
(770) 996-6699
(770) 692-2669
Mailing address
119 AMBULANCE DR 202, CARROLLTON, GA 30117-3857
(770) 838-8710
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
005897
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
005897
GEORGIA MEDICAL LICENSE
GA
Enumeration date
09/09/2010
Last updated
11/23/2015
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