Basic Information
| Provider Information | |||||||||
| NPI: | 1255866943 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | JUAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | PA-C, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742616 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702198420 | ||||||||
| FaxNumber: | 7702198440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1404 RIVER PL STE 401 | ||||||||
| Address2: | |||||||||
| City: | BRASELTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305175600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708486190 | ||||||||
| FaxNumber: | 7708485367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2017 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008400 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 008400 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.