Provider Demographics
NPI:1811473556
Name:BUREAU, DIANNA JOHNSON (PA)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:JOHNSON
Last Name:BUREAU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1755 HIGHWAY 34 E STE 2200
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3190
Mailing Address - Country:US
Mailing Address - Phone:770-502-2175
Mailing Address - Fax:770-254-7837
Practice Address - Street 1:1755 HIGHWAY 34 E STE 2200
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-3190
Practice Address - Country:US
Practice Address - Phone:770-502-2175
Practice Address - Fax:770-254-7837
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty