Provider Demographics
NPI:1699446963
Name:RUSU, VANESSA EZABELLA (PA-C)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:EZABELLA
Last Name:RUSU
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 1:3651 PEACHTREE PKWY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6034
Mailing Address - Country:US
Mailing Address - Phone:770-628-3005
Mailing Address - Fax:770-299-0845
Practice Address - Street 1:3651 PEACHTREE PKWY STE B
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1089
Practice Address - Country:US
Practice Address - Phone:770-628-3005
Practice Address - Fax:770-299-0845
Is Sole Proprietor?:No
Enumeration Date:2021-09-25
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X
GA11498363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant