Provider Demographics
NPI:1013577873
Name:RAINBOLT, BRYAN (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:RAINBOLT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4101
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4542
Mailing Address - Country:US
Mailing Address - Phone:770-831-5525
Mailing Address - Fax:
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4101
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4542
Practice Address - Country:US
Practice Address - Phone:770-831-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty