Provider Demographics
NPI:1750045373
Name:MORAN, REBECCA COLLINS
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:COLLINS
Last Name:MORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HOWELL MILL RD NW STE 800
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-0922
Mailing Address - Country:US
Mailing Address - Phone:678-298-3239
Mailing Address - Fax:404-477-1162
Practice Address - Street 1:775 POPLAR RD STE 310
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8303
Practice Address - Country:US
Practice Address - Phone:770-251-2590
Practice Address - Fax:770-251-1410
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11156363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11156OtherGEORGIA COMPOSITE MEDICAL BOARD