Provider Demographics
NPI:1467876193
Name:VARDAMAN, ROBERT II (AGACNP)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:VARDAMAN
Suffix:II
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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 1:1315 JESSE JEWELL PKWY NE STE 300
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3875
Practice Address - Country:US
Practice Address - Phone:770-219-6520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-17
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM69138363LA2100X
FL11020905363LA2100X
GARN214917363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care