Provider Demographics
NPI:1831333012
Name:ERRIDGE, ALISA ANN (MSPAS)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:ANN
Last Name:ERRIDGE
Suffix:
Gender:F
Credentials:MSPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:95 COLLIER ROAD, NW
Mailing Address - Street 2:SUITE 5015
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1721
Mailing Address - Country:US
Mailing Address - Phone:404-605-5699
Mailing Address - Fax:404-355-4235
Practice Address - Street 1:95 COLLIER ROAD, NW
Practice Address - Street 2:SUITE 5015
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1721
Practice Address - Country:US
Practice Address - Phone:404-605-5699
Practice Address - Fax:404-355-4235
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005542363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106435AMedicaid
GA202I976888Medicare PIN