Provider Demographics
NPI:1124014246
Name:DALEY, TRISHA N (MD)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:N
Last Name:DALEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 SANDERS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5962
Mailing Address - Country:US
Mailing Address - Phone:770-205-0104
Mailing Address - Fax:770-205-0975
Practice Address - Street 1:960 SANDERS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5962
Practice Address - Country:US
Practice Address - Phone:770-205-0104
Practice Address - Fax:770-205-0975
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237350207N00000X
GA059398207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA421508605AMedicaid
NY02578361Medicaid
NY3K6101Medicare PIN
GA421508605AMedicaid
NY0159AAMedicare PIN