Healthcare Provider Details

I. General information

NPI: 1972856961
Provider Name (Legal Business Name): SHIRLEY EPHRAIM BASSEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER STREET SUITE 160
MARIETTA GA
30060
US

IV. Provider business mailing address

2187 CHEROKEE VALLEY CIR
LITHONIA GA
30058-5365
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1372
  • Fax:
Mailing address:
  • Phone: 404-285-4380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6593
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: