Provider Demographics
NPI:1134749930
Name:STANTON, ELISSA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:ANN
Last Name:STANTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:STANTON
Other - Last Name:RICKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3987 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2586
Mailing Address - Country:US
Mailing Address - Phone:770-689-8936
Mailing Address - Fax:
Practice Address - Street 1:3987 BROWN RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-2586
Practice Address - Country:US
Practice Address - Phone:770-689-8936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant