Provider Demographics
NPI:1235432170
Name:MUNSANTO, DEIDRA DYAN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:DEIDRA
Middle Name:DYAN
Last Name:MUNSANTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:DEIDRA
Other - Middle Name:DYAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12201 HIGHWAY 92 STE D
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:770-517-4621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1937363A00000X
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant