Provider Demographics
NPI:1649425869
Name:KOBLASZ, BOBBI J (AAC)
Entity type:Individual
Prefix:
First Name:BOBBI
Middle Name:J
Last Name:KOBLASZ
Suffix:
Gender:F
Credentials:AAC
Other - Prefix:
Other - First Name:BOBBI
Other - Middle Name:J
Other - Last Name:BOURLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AAC
Mailing Address - Street 1:3155 N POINT PKWY STE F100
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5495
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:770-645-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005463367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA231252198BMedicaid