Provider Demographics
NPI:1386633832
Name:HAIRSTON, PETER JEFF (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JEFF
Last Name:HAIRSTON
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 1:300 TOWER RD NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9403
Mailing Address - Country:US
Mailing Address - Phone:770-427-5717
Mailing Address - Fax:770-429-6503
Practice Address - Street 1:300 TOWER RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9403
Practice Address - Country:US
Practice Address - Phone:770-427-5717
Practice Address - Fax:770-429-6503
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309477474AMedicaid
GA309477474AMedicaid
GAP11351Medicare UPIN