Provider Demographics
NPI:1043249261
Name:PILLOT MAGEE, EBONIQUE C (PA-C)
Entity Type:Individual
Prefix:
First Name:EBONIQUE
Middle Name:C
Last Name:PILLOT MAGEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 BRIAR CREEK CT NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-7123
Mailing Address - Country:US
Mailing Address - Phone:404-421-6966
Mailing Address - Fax:
Practice Address - Street 1:5910 HILLANDALE DR STE 301
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-1880
Practice Address - Country:US
Practice Address - Phone:707-987-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA758372220BMedicaid
GA758372220CMedicaid
GA758372220DMedicaid
GA758372220EMedicaid
GA758372220AMedicaid
GA758372220DMedicaid
GA97WCGNVMedicare PIN