Provider Demographics
NPI:1083994495
Name:DOUGLASS, BRIAN CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:CHRISTOPHER
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 13TH ST NE APT 603
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3699
Mailing Address - Country:US
Mailing Address - Phone:913-634-0571
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2208
Practice Address - Country:US
Practice Address - Phone:404-686-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004083363A00000X
GA006574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant