Basic Information
Provider Information | |||||||||
NPI: | 1316133937 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OSBORNE | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | B. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAAA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRONIKOWSKI | ||||||||
OtherFirstName: | LAUREN | ||||||||
OtherMiddleName: | S. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAAA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3155 N POINT PKWY | ||||||||
Address2: | ATTN: CREDENTIALING DEPT., BUILDING F, SUITE 100 | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706459181 | ||||||||
FaxNumber: | 7706458455 | ||||||||
Practice Location | |||||||||
Address1: | 1000 JOHNSON FERRY ROAD | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706459181 | ||||||||
FaxNumber: | 7706458455 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/18/2007 | ||||||||
LastUpdateDate: | 12/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 5132 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 655711584B | 05 | GA |   | MEDICAID | 655711584A | 05 | GA |   | MEDICAID | 655711584C | 05 | GA |   | MEDICAID |