Individual
MRS. BRENA JOHNSON SIDDALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
280 E WILLOW CREEK LN, MC RAE, GA 31055-5126
(478) 864-3448
(478) 864-1288
Mailing address
2251 W ELM ST, WRIGHTSVILLE, GA 31096-2017
(478) 864-3448
(478) 864-1288
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
3400
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003400
GEORGIA LICENSE
GA
Enumeration date
08/24/2007
Last updated
08/20/2015
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