Provider Demographics
NPI:1457508806
Name:DOUGLAS, DANIEL R (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:758 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3385
Mailing Address - Country:US
Mailing Address - Phone:770-962-4300
Mailing Address - Fax:770-339-7544
Practice Address - Street 1:758 OLD NORCROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3385
Practice Address - Country:US
Practice Address - Phone:770-962-4300
Practice Address - Fax:770-339-7544
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2010-10-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA005875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA814393183AMedicaid
GA202I979026Medicare PIN