Provider Demographics
NPI:1225284367
Name:VAUGHAN, ROLANDINE (PAC)
Entity Type:Individual
Prefix:
First Name:ROLANDINE
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2084 MITFORD CT
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2486
Mailing Address - Country:US
Mailing Address - Phone:678-960-8953
Mailing Address - Fax:678-302-7377
Practice Address - Street 1:1862 AUBURN RD STE 118-X1
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1676
Practice Address - Country:US
Practice Address - Phone:404-906-6985
Practice Address - Fax:678-302-7377
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005982174400000X, 363A00000X
VA0110002860363A00000X
363A00000X
IN10004230A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00429217DMedicaid
GAE27511Medicare UPIN
GA89BDDLPMedicare PIN