Provider Demographics
NPI:1396953873
Name:LASSITER, MICHAEL GREGORY (SURGICAL ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:LASSITER
Suffix:
Gender:M
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3577A CHAMBLEE TUCKER RD #161
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1459
Mailing Address - Country:US
Mailing Address - Phone:404-432-8746
Mailing Address - Fax:
Practice Address - Street 1:3577 CHAMBLEE TUCKER RD # 161A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4422
Practice Address - Country:US
Practice Address - Phone:404-432-8746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2795363AS0400X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant