Healthcare Provider Details

I. General information

NPI: 1194706234
Provider Name (Legal Business Name): ELISABETH JACKSON GAINES I PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4586 TIMBER RIDGE DR STE 200
DOUGLASVILLE GA
30135-7514
US

IV. Provider business mailing address

1835 SAVOY DR SUITE 300
ATLANTA GA
30341-1072
US

V. Phone/Fax

Practice location:
  • Phone: 770-942-0457
  • Fax: 770-942-7699
Mailing address:
  • Phone: 770-942-0457
  • Fax: 770-942-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003791
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: