Provider Demographics
NPI:1205935095
Name:BAILEY, DIANNE ELISABETH (PA-C)
Entity type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:ELISABETH
Last Name:BAILEY
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 1:620 PEACHTREE ST
Mailing Address - Street 2:UNIT # 1410
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2313
Mailing Address - Country:US
Mailing Address - Phone:404-931-1109
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:DEPT. OF CARDIOTHORACIC SURGERY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-686-2513
Practice Address - Fax:404-686-4959
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR74324001Medicare UPIN
GA97BBBCHMedicare ID - Type Unspecified