Provider Demographics
NPI:1609107457
Name:WINOKUR, VANESSA MARCY (PA-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARCY
Last Name:WINOKUR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:DENNISE
Other - Last Name:MARCY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3790 W NANCY CREEK CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1629
Mailing Address - Country:US
Mailing Address - Phone:678-637-9580
Mailing Address - Fax:
Practice Address - Street 1:210 VILLAGE CENTER PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9044
Practice Address - Country:US
Practice Address - Phone:770-474-5952
Practice Address - Fax:770-474-2187
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003607363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA972775844AMedicaid
Q13244Medicare UPIN
GA972775844AMedicaid