Provider Demographics
NPI:1568438216
Name:PERRY, PATRICIA T (PA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:T
Last Name:PERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 HIGHWAY 54 W
Mailing Address - Street 2:BLDG 500
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4535
Mailing Address - Country:US
Mailing Address - Phone:770-461-1238
Mailing Address - Fax:770-460-6610
Practice Address - Street 1:1336 HIGHWAY 54 W
Practice Address - Street 2:BLDG 500
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4535
Practice Address - Country:US
Practice Address - Phone:770-461-1238
Practice Address - Fax:770-460-6610
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR80810Medicare UPIN
GA97WCFNRMedicare PIN