Healthcare Provider Details

I. General information

NPI: 1396953873
Provider Name (Legal Business Name): MICHAEL GREGORY LASSITER SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3577 CHAMBLEE TUCKER RD # 161A
ATLANTA GA
30341-4422
US

IV. Provider business mailing address

3577A CHAMBLEE TUCKER RD #161
ATLANTA GA
30341-1459
US

V. Phone/Fax

Practice location:
  • Phone: 404-432-8746
  • Fax:
Mailing address:
  • Phone: 404-432-8746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2795
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number2795
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: