Provider Demographics
NPI:1033470075
Name:GUSICK, REENA T (PA)
Entity Type:Individual
Prefix:MRS
First Name:REENA
Middle Name:T
Last Name:GUSICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REENA
Other - Middle Name:
Other - Last Name:TAANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:404-256-4777
Mailing Address - Fax:404-256-5515
Practice Address - Street 1:1100 JOHNSON FERRY RD STE 600
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1739
Practice Address - Country:US
Practice Address - Phone:404-256-4777
Practice Address - Fax:404-256-5515
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
GA006516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I978507OtherMEDICARE PTAN
GA003126804KMedicaid