Basic Information
| Provider Information | |||||||||
| NPI: | 1700813581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | JANNA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1838 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709957622 | ||||||||
| FaxNumber: | 7709957854 | ||||||||
| Practice Location | |||||||||
| Address1: | 5665 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042526104 | ||||||||
| FaxNumber: | 4042571808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT830 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 5762 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003123470A | 05 | GA | MEDICAID |