Provider Demographics
NPI:1760420202
Name:DOAK, ANDREA BYRD (PAC)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:BYRD
Last Name:DOAK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30434-1558
Mailing Address - Country:US
Mailing Address - Phone:478-625-8471
Mailing Address - Fax:478-625-8477
Practice Address - Street 1:1067 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434
Practice Address - Country:US
Practice Address - Phone:478-625-8471
Practice Address - Fax:478-625-8477
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002743363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000139CMedicaid
GA100000139AMedicaid
GA100000140AMedicaid
GA97WCSWFMedicare PIN
GA97BBCGBMedicare ID - Type Unspecified
GA100000139AMedicaid