Provider Demographics
NPI:1194895482
Name:BHAKTA, BINA MOHANBHAI (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:BINA
Middle Name:MOHANBHAI
Last Name:BHAKTA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 OLD STILESBORO RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3140
Mailing Address - Country:US
Mailing Address - Phone:770-312-6385
Mailing Address - Fax:
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:470-788-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34962084A2900X
GA003496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
P50216001Medicare UPIN
GA97WCGNRMedicare ID - Type Unspecified