Provider Demographics
NPI:1942244157
Name:DEWOODY, RAE RILEY (PA-C)
Entity Type:Individual
Prefix:
First Name:RAE
Middle Name:RILEY
Last Name:DEWOODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 920
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2777
Mailing Address - Fax:
Practice Address - Street 1:2801 DEKALB MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4996
Practice Address - Country:US
Practice Address - Phone:404-501-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA002645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001061DMedicaid
GA100001061BMedicaid
GA100001061CMedicaid
CAS50601Medicare UPIN
GA97WCGRQMedicare ID - Type Unspecified
GA100001061BMedicaid
GA100001061DMedicaid