Healthcare Provider Details

I. General information

NPI: 1437481256
Provider Name (Legal Business Name): CONNIE REYNOLDS BOATMAN MPA, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONNIE MARIE REYNOLDS MPA, PA-C

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE DAVIS FISCHER BUILDING OFFICE 3245A
ATLANTA GA
30308-2208
US

IV. Provider business mailing address

550 PEACHTREE ST NE DAVIS FISCHER BUILDING OFFICE 3245A
ATLANTA GA
30308-2208
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-7841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005690
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: