Provider Demographics
NPI:1760530265
Name:MADARIAGA, SANDRA (AA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MADARIAGA
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1984 PEACHTREE RD NW
Mailing Address - Street 2:SUITE 515
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-5219
Mailing Address - Country:US
Mailing Address - Phone:404-351-1745
Mailing Address - Fax:404-351-7121
Practice Address - Street 1:1984 PEACHTREE RD NW
Practice Address - Street 2:SUITE 515
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-5219
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002463367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00505755CMedicaid
GA43ZCBDB34Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER