Healthcare Provider Details

I. General information

NPI: 1295309441
Provider Name (Legal Business Name): JONATHAN EDWARD RIORDAN PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 COLLIER RD NW STE 300
ATLANTA GA
30309-1740
US

IV. Provider business mailing address

1011 RIDGECREST DR SE
SMYRNA GA
30080-4230
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-0009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10479
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: