Healthcare Provider Details

I. General information

NPI: 1659895373
Provider Name (Legal Business Name): SUDHISHA KUMARI JALA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD STE 820
ATLANTA GA
30342-1608
US

IV. Provider business mailing address

1355 PEACHTREE ST NE STE 1600
ATLANTA GA
30309-3276
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9307
  • Fax: 404-252-5839
Mailing address:
  • Phone: 770-989-1623
  • Fax: 678-388-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number008523
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: