Basic Information
| Provider Information | |||||||||
| NPI: | 1326070228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | GARNEDA | ||||||||
| MiddleName: | DAVONIA | ||||||||
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| Credential: | PAAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4973 KIOWA CT SW | ||||||||
| Address2: | |||||||||
| City: | LILBURN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300475776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704133302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST | ||||||||
| Address2: | ANESTHESIOLOGY 2ND FLOOR | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047784852 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 002469 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 2469 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100002495A | 05 | GA | MEDICAID |