Healthcare Provider Details

I. General information

NPI: 1043606262
Provider Name (Legal Business Name): KALEY RAE SPEROS LAMAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 EXECUTIVE PARK S STE 3000
ATLANTA GA
30329-2208
US

IV. Provider business mailing address

59 EXECUTIVE PARK S STE 3000
ATLANTA GA
30329-2208
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-6227
  • Fax: 404-778-6310
Mailing address:
  • Phone: 404-778-6227
  • Fax: 404-778-6310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7530
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: