Provider Demographics
NPI:1255401527
Name:DENZIN, DAMON ROBERT (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:ROBERT
Last Name:DENZIN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 DEVONWOOD TRL NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5440
Mailing Address - Country:US
Mailing Address - Phone:678-687-0229
Mailing Address - Fax:
Practice Address - Street 1:61 WHITCHER ST NE
Practice Address - Street 2:SUITE 4100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1176
Practice Address - Country:US
Practice Address - Phone:770-590-4180
Practice Address - Fax:770-590-4187
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002309AMedicaid
GA100002309AMedicaid
GA97WCCMDMedicare ID - Type Unspecified