Provider Demographics
NPI:1972021962
Name:MIDANAKY, OMID (PA-C)
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:MIDANAKY
Suffix:
Gender:M
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 1:810 WHISPERWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7586
Mailing Address - Country:US
Mailing Address - Phone:404-704-2813
Mailing Address - Fax:
Practice Address - Street 1:2801 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5949
Practice Address - Country:US
Practice Address - Phone:404-296-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant