MEDICARE: MS. JENNY H THAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5594	GA

General Provider Information

NPI Number	:	1467787655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNY H THAN PA-C

Provider Business Mailing Address
First Line	:	2052 HOSEA L WILLIAMS DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30317-2502
Country	:	US
Telephone Number	:	404-607-1002
Fax Number	:	404-607-1031

Provider Business Practice Location Address
First Line	:	2052 HOSEA L WILLIAMS DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30317-2502
Country	:	US
Telephone Number	:	404-607-1002
Fax Number	:	404-607-1031

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2009
Last Update Date	:	03/29/2010

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