Provider Demographics
NPI:1750494308
Name:SUPRUNIUK, IRINA (PA - C)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:SUPRUNIUK
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 1:35 COLLIER ROAD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309
Mailing Address - Country:US
Mailing Address - Phone:404-355-1966
Mailing Address - Fax:404-603-2801
Practice Address - Street 1:35 COLLIER ROAD
Practice Address - Street 2:SUITE 150
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-355-1966
Practice Address - Fax:404-603-2801
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003613363A00000X
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ71062Medicare UPIN