Provider Demographics
NPI:1558882381
Name:THEODORE, ANTOINETTE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANTOINETTE
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:THEODORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:5635 PEACHTREE PKWY STE 180
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2823
Mailing Address - Country:US
Mailing Address - Phone:470-938-6670
Mailing Address - Fax:678-272-3144
Practice Address - Street 1:5635 PEACHTREE PKWY STE 180
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-2823
Practice Address - Country:US
Practice Address - Phone:470-938-6670
Practice Address - Fax:678-272-3144
Is Sole Proprietor?:No
Enumeration Date:2017-07-01
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10250363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical