Provider Demographics
NPI:1194272542
Name:NIKNEZHAD, LINDSEY PANTER (PA-C)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:PANTER
Last Name:NIKNEZHAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVERSTONE VIS
Mailing Address - Street 2:STE 203
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6668
Mailing Address - Country:US
Mailing Address - Phone:706-258-4142
Mailing Address - Fax:706-633-6451
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-632-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8087363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202974I585Medicare PIN