Provider Demographics
NPI:1295826105
Name:VASSILIOU, VASSILAKIS (PA-C)
Entity Type:Individual
Prefix:
First Name:VASSILAKIS
Middle Name:
Last Name:VASSILIOU
Suffix:
Gender:M
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 1:55 WHITCHER STREET
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1129
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:
Practice Address - Street 1:460 NORTHSIDE CHEROKEE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8017
Practice Address - Country:US
Practice Address - Phone:678-493-2527
Practice Address - Fax:678-593-5608
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004684363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000456211CMedicaid
GA000456211GMedicaid
GA000456211DMedicaid
GA000456211FMedicaid
GA000456211EMedicaid
GA000456211FMedicaid