Healthcare Provider Details

I. General information

NPI: 1174550693
Provider Name (Legal Business Name): STEPHANIE SUMMERHILL-BRCKA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE SUMMERHILL PA

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOUNT ZION PKWY
JONESBORO GA
30236-2500
US

IV. Provider business mailing address

3495 PIEDMONT RD NE
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 404-365-0966
  • Fax:
Mailing address:
  • Phone: 404-364-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103206
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number75264
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007885
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: