Healthcare Provider Details

I. General information

NPI: 1093531196
Provider Name (Legal Business Name): GENESIS E ORELLANA PERDOMO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 SUMMER RIDGE LN
LAWRENCEVILLE GA
30044-3939
US

IV. Provider business mailing address

815 SUMMER RIDGE LN
LAWRENCEVILLE GA
30044-3939
US

V. Phone/Fax

Practice location:
  • Phone: 678-852-8014
  • Fax:
Mailing address:
  • Phone: 678-852-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13599
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: