Provider Demographics
NPI:1962186759
Name:FRAZIER, TATA-NISHA (CPS-MD, AD)
Entity type:Individual
Prefix:
First Name:TATA-NISHA
Middle Name:
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:CPS-MD, AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4037 BROWNE CT
Mailing Address - Street 2:
Mailing Address - City:CONLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30288-6811
Mailing Address - Country:US
Mailing Address - Phone:404-263-2478
Mailing Address - Fax:404-973-0276
Practice Address - Street 1:504 FAIR ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30313-1206
Practice Address - Country:US
Practice Address - Phone:470-896-6046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty