Basic Information
| Provider Information | |||||||||
| NPI: | 1336386127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAGNANDAN | ||||||||
| FirstName: | DAVIN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PAAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3155 N POINT PKWY | ||||||||
| Address2: | BUILDING F, SUITE 100, ATTN: CREDENTIALING | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300055481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 JOHNSON FERRY RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 02/27/2009 | ||||||||
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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 | 367H00000X | 005505 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 510079924A | 05 | GA | MEDICAID |