Provider Demographics
NPI:1790978526
Name:SIDDALL, BRENA JOHNSON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BRENA
Middle Name:JOHNSON
Last Name:SIDDALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRENA
Other - Middle Name:LAGALE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2251 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-2017
Mailing Address - Country:US
Mailing Address - Phone:478-864-3448
Mailing Address - Fax:478-864-1288
Practice Address - Street 1:280 E WILLOW CREEK LN
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-5126
Practice Address - Country:US
Practice Address - Phone:478-864-3448
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003400OtherGEORGIA LICENSE