Provider Demographics
NPI:1619753092
Name:AMAYA, CARLOS ALBERTO (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALBERTO
Last Name:AMAYA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 DEER RUN CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5935
Mailing Address - Country:US
Mailing Address - Phone:423-453-1772
Mailing Address - Fax:
Practice Address - Street 1:1810 MULKEY RD STE 202
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1150
Practice Address - Country:US
Practice Address - Phone:770-694-6349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11842363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical