Provider Demographics
NPI:1245483486
Name:DIMARE, ANGELA TISON (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:TISON
Last Name:DIMARE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:C
Other - Last Name:TISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 TOWER ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9403
Mailing Address - Country:US
Mailing Address - Phone:770-427-5717
Mailing Address - Fax:770-514-6744
Practice Address - Street 1:300 TOWER ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9403
Practice Address - Country:US
Practice Address - Phone:770-427-5717
Practice Address - Fax:770-514-6744
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005464363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I974290Medicare PIN