Basic Information
| Provider Information | |||||||||
| NPI: | 1609916113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNETTE | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | ELSTON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELSTON | ||||||||
| OtherFirstName: | TANYA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 980 JOHNSON FERRY RD | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043033320 | ||||||||
| FaxNumber: | 4043033464 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 JOHNSON FERRY RD | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043033320 | ||||||||
| FaxNumber: | 4043033464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 003677 | GA | N | Other Service Providers | Specialist | 363A00000X | 003677 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.