Basic Information
Provider Information | |||||||||
NPI: | 1255362729 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ATLANTA VA MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4366 IDLEWOOD LN | ||||||||
Address2: |   | ||||||||
City: | TUCKER | ||||||||
State: | GA | ||||||||
PostalCode: | 300846437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707128249 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1670 CLAIRMONT RD | ||||||||
Address2: | ATLANTA VA | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300334004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043216111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 11/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALEXANDER | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | RAY | ||||||||
AuthorizedOfficialTitleorPosition: | NURSE PRACTIONER | ||||||||
AuthorizedOfficialTelephone: | 4043216111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | APRN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | RN 096164-NP | GA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.