Provider Demographics
NPI:1588055891
Name:LIATIS, ANDREA I (PA-C)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:I
Last Name:LIATIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
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:770-496-5555
Mailing Address - Fax:770-939-2887
Practice Address - Street 1:2712 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2512
Practice Address - Country:US
Practice Address - Phone:770-496-5555
Practice Address - Fax:770-939-2887
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA7492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003156873EMedicaid
GA003156873FMedicaid
GA202I975284OtherMEDICARE PTAN
GA003156873DMedicaid