Provider Demographics
NPI:1891973483
Name:BACOT, ELIZA JOHNSON (NP)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:JOHNSON
Last Name:BACOT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CELEBRATE LIFE PKWY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8001
Mailing Address - Country:US
Mailing Address - Phone:678-907-2999
Mailing Address - Fax:
Practice Address - Street 1:600 CELEBRATE LIFE PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8001
Practice Address - Country:US
Practice Address - Phone:678-907-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN168366363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA220573126AMedicaid
GA220573126AMedicaid