Provider Demographics
NPI:1194706234
Name:GAINES, ELISABETH JACKSON I (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:JACKSON
Last Name:GAINES
Suffix:I
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:770-942-0457
Mailing Address - Fax:770-942-7699
Practice Address - Street 1:4586 TIMBER RIDGE DR STE 200
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7514
Practice Address - Country:US
Practice Address - Phone:770-942-0457
Practice Address - Fax:770-942-7699
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2020-12-07
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Provider Licenses
StateLicense IDTaxonomies
GA003791363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003101476BMedicaid
GA202I970546OtherMEDICARE PTAN