Provider Demographics
NPI:1700812328
Name:BROUILLARD, RICHARD GEORGE (PAAA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GEORGE
Last Name:BROUILLARD
Suffix:
Gender:M
Credentials:PAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:784 CRESTRIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3621
Mailing Address - Country:US
Mailing Address - Phone:404-872-0653
Mailing Address - Fax:404-778-5194
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1059
Practice Address - Country:US
Practice Address - Phone:404-778-3900
Practice Address - Fax:404-778-5194
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000961367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant