Provider Demographics
NPI:1659329514
Name:BRASELTON, DAVINA SARA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DAVINA
Middle Name:SARA
Last Name:BRASELTON
Suffix:
Gender:F
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 1:605 S. ENOTA DR.
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:770-538-0208
Mailing Address - Fax:770-538-0556
Practice Address - Street 1:605 S. ENOTA DR.
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-538-0208
Practice Address - Fax:770-538-0556
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0044136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCGGXMedicare UPIN