Healthcare Provider Details

I. General information

NPI: 1144316613
Provider Name (Legal Business Name): RAY JARVIS P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 CLIFTON ROAD
ATLANTA GA
30322-4200
US

IV. Provider business mailing address

1479 HICKORY LANE
LILBURN GA
30047-4425
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7551
  • Fax: 404-727-3859
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000664
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: