Provider Demographics
NPI:1194902791
Name:ITZIE, DAWN MAZIE (PA-C)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MAZIE
Last Name:ITZIE
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 1:771 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4386
Mailing Address - Country:US
Mailing Address - Phone:770-963-2967
Mailing Address - Fax:770-339-4585
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:SUITE 255
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:770-963-2967
Practice Address - Fax:770-339-4585
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003340363A00000X, 363A00000X
GA#3340363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003340OtherSTATE LICENSE
GA003340OtherSTATE LICENSE
GA685464813AMedicaid
GA511L970213Medicare PIN