Provider Demographics
NPI:1487763355
Name:VASSIAN, SHIARA (PA)
Entity type:Individual
Prefix:
First Name:SHIARA
Middle Name:
Last Name:VASSIAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 945934
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5934
Mailing Address - Country:US
Mailing Address - Phone:770-788-0620
Mailing Address - Fax:678-342-3327
Practice Address - Street 1:4155 BAKER ST NE
Practice Address - Street 2:SUITE 100
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1405
Practice Address - Country:US
Practice Address - Phone:770-788-0620
Practice Address - Fax:678-342-3327
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003545207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5909OtherKAISER PROVIDER #
GA97WCCNJMedicare PIN
GAP58720Medicare UPIN
GA5909OtherKAISER PROVIDER #