Provider Demographics
NPI:1609916113
Name:BURNETTE, TANYA ELSTON (PA)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:ELSTON
Last Name:BURNETTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:TANYA
Other - Middle Name:KAY
Other - Last Name:ELSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:980 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1626
Mailing Address - Country:US
Mailing Address - Phone:404-303-3320
Mailing Address - Fax:404-303-3464
Practice Address - Street 1:980 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 520
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1626
Practice Address - Country:US
Practice Address - Phone:404-303-3320
Practice Address - Fax:404-303-3464
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003677174400000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist