Provider Demographics
NPI:1306357256
Name:DELISSER, HORACE MICHAEL JR (PA)
Entity Type:Individual
Prefix:MR
First Name:HORACE
Middle Name:MICHAEL
Last Name:DELISSER
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:426 EXCHANGE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:GA
Practice Address - Zip Code:30620-1794
Practice Address - Country:US
Practice Address - Phone:770-848-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
GA11352363AS0400X
PAMA059415363AS0400X
NJ25MP00494800363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty