Provider Demographics
NPI:1528399169
Name:VELASCO, PATRICIA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:
Last Name:VELASCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:SERNA
Other - Suffix:
Other - Last Name Type:Former Name
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 1:1439 JESSE JEWELL PKWY NE STE 301
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3806
Practice Address - Country:US
Practice Address - Phone:770-219-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5738363A00000X
GA005738363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant