Provider Demographics
NPI:1588894430
Name:DAFTARI, ANISA T (PA)
Entity type:Individual
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First Name:ANISA
Middle Name:T
Last Name:DAFTARI
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Gender:F
Credentials:PA
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Mailing Address - Street 1:4380 GEORGETOWN SQ
Mailing Address - Street 2:STE 1002
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6254
Mailing Address - Country:US
Mailing Address - Phone:770-220-8400
Mailing Address - Fax:770-234-9979
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:STE150
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-297-1780
Practice Address - Fax:770-234-9979
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2020-08-28
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Provider Licenses
StateLicense IDTaxonomies
GA3298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003298OtherPHYSICIAN ASSISTANT LICENSE