Provider Demographics
NPI:1821149139
Name:PESHEL, TABATHA (NP)
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:PESHEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:100 STONEFOREST DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4881
Mailing Address - Country:US
Mailing Address - Phone:678-388-1610
Mailing Address - Fax:678-388-1627
Practice Address - Street 1:148 BILL CARRUTH PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3754
Practice Address - Country:US
Practice Address - Phone:678-324-4444
Practice Address - Fax:770-528-9932
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA115803363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA115511749CMedicaid
GA115511749EMedicaid
GA115511749GMedicaid
GA115511749DMedicaid
GA115511749FMedicaid
GA115511749FMedicaid