Healthcare Provider Details

I. General information

NPI: 1750369021
Provider Name (Legal Business Name): ANDREA REGINA MCINTOSH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 05/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5669 PEACHTREE DUNWOODY RD NE SUITE #210
ATLANTA GA
30342-1786
US

IV. Provider business mailing address

1872 MONTREAL RD
TUCKER GA
30084-5709
US

V. Phone/Fax

Practice location:
  • Phone: 404-255-4333
  • Fax: 404-255-0601
Mailing address:
  • Phone: 770-496-9400
  • Fax: 770-496-9495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4520
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: