Provider Demographics
NPI:1578520342
Name:FAWLEY, JONIE D (PA)
Entity Type:Individual
Prefix:
First Name:JONIE
Middle Name:D
Last Name:FAWLEY
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 1:4500 N SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6476
Mailing Address - Country:US
Mailing Address - Phone:404-778-6920
Mailing Address - Fax:404-778-6901
Practice Address - Street 1:4500 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6476
Practice Address - Country:US
Practice Address - Phone:404-778-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P70720Medicare UPIN
FAPA19851Medicare ID - Type Unspecified
PA19851Medicare PIN