Healthcare Provider Details

I. General information

NPI: 1760677322
Provider Name (Legal Business Name): ALYSHA S JAFFER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2536 LAWRENCEVILLE HWY
DECATUR GA
30033-3227
US

IV. Provider business mailing address

755 WALTHER RD
LAWRENCEVILLE GA
30046-8725
US

V. Phone/Fax

Practice location:
  • Phone: 770-934-6832
  • Fax: 770-934-6337
Mailing address:
  • Phone: 770-290-8087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005146
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number001615
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1615
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: