Healthcare Provider Details

I. General information

NPI: 1225284367
Provider Name (Legal Business Name): ROLANDINE VAUGHAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 03/15/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1862 AUBURN RD STE 118-X1
DACULA GA
30019-1676
US

IV. Provider business mailing address

2084 MITFORD CT
DACULA GA
30019-2486
US

V. Phone/Fax

Practice location:
  • Phone: 404-906-6985
  • Fax: 678-302-7377
Mailing address:
  • Phone: 678-960-8953
  • Fax: 678-302-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002860
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005982
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004230A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number005982
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: