Healthcare Provider Details

I. General information

NPI: 1194895482
Provider Name (Legal Business Name): BINA MOHANBHAI BHAKTA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

4170 OLD STILESBORO RD NW
KENNESAW GA
30152-3140
US

V. Phone/Fax

Practice location:
  • Phone: 470-788-1010
  • Fax:
Mailing address:
  • Phone: 770-312-6385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003496
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number3496
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: