Provider Demographics
NPI:1194952408
Name:MIRAMONTES, ROQUE (PA, MPH)
Entity type:Individual
Prefix:
First Name:ROQUE
Middle Name:
Last Name:MIRAMONTES
Suffix:
Gender:M
Credentials:PA, MPH
Other - Prefix:
Other - First Name:ROQUE
Other - Middle Name:
Other - Last Name:MIRAMONTES
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1600 CLIFTON RD NE
Mailing Address - Street 2:MS: E-10
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4018
Mailing Address - Country:US
Mailing Address - Phone:404-639-6306
Mailing Address - Fax:404-929-2854
Practice Address - Street 1:1600 CLIFTON RD NE
Practice Address - Street 2:MS: E-10
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4018
Practice Address - Country:US
Practice Address - Phone:404-639-6306
Practice Address - Fax:404-929-2854
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005548363A00000X
CAPA16051363A00000X
WAPA10004457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant