Provider Demographics
NPI:1831261395
Name:RILEY, RETAUNDA MONIQUE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:RETAUNDA
Middle Name:MONIQUE
Last Name:RILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 CANNOLI CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3907
Mailing Address - Country:US
Mailing Address - Phone:770-288-2479
Mailing Address - Fax:
Practice Address - Street 1:1701 HARDEE AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30330-1062
Practice Address - Country:US
Practice Address - Phone:404-464-0469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1054922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant