Provider Demographics
NPI:1740987726
Name:REBURIANO, ALLYSSA KAREN (PAC)
Entity type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:KAREN
Last Name:REBURIANO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 NORTHSIDE BLVD STE 2400
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7662
Mailing Address - Country:US
Mailing Address - Phone:770-292-3490
Mailing Address - Fax:770-292-9016
Practice Address - Street 1:1505 NORTHSIDE BLVD STE 2400
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7662
Practice Address - Country:US
Practice Address - Phone:770-292-3490
Practice Address - Fax:770-292-9016
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant