Provider Demographics
NPI:1992943195
Name:BASS BURCH, DANA B (PA)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:B
Last Name:BASS BURCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:B
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:794 MCDONOUGH RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1572
Mailing Address - Country:US
Mailing Address - Phone:470-251-5300
Mailing Address - Fax:470-251-5301
Practice Address - Street 1:794 MCDONOUGH RD
Practice Address - Street 2:SUITE 111
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1572
Practice Address - Country:US
Practice Address - Phone:470-251-5300
Practice Address - Fax:470-251-5301
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1843363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical