Healthcare Provider Details

I. General information

NPI: 1902580772
Provider Name (Legal Business Name): NIDHA JIVAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TREE LN STE 250
SNELLVILLE GA
30078-6799
US

IV. Provider business mailing address

410 MEIJER DR
FLORENCE KY
41042-5128
US

V. Phone/Fax

Practice location:
  • Phone: 770-736-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number11663
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11663
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: