Provider Demographics
NPI:1063625051
Name:HAIRSTON, JEFFREY N (PA-C)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:N
Last Name:HAIRSTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2041 MESA VALLEY WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6828
Mailing Address - Country:US
Mailing Address - Phone:770-944-1100
Mailing Address - Fax:770-941-7227
Practice Address - Street 1:2041 MESA VALLEY WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6828
Practice Address - Country:US
Practice Address - Phone:770-944-1100
Practice Address - Fax:770-941-7227
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002922363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA507133071FMedicaid
GA507133071EMedicaid
GA507133071GMedicaid
GA507133071EMedicaid