Healthcare Provider Details

I. General information

NPI: 1013822857
Provider Name (Legal Business Name): IAN ANANTHASANE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 JOHNS CREEK PKWY
SUWANEE GA
30024-5682
US

IV. Provider business mailing address

4025 JOHNS CREEK PKWY STE 100
SUWANEE GA
30024-5683
US

V. Phone/Fax

Practice location:
  • Phone: 404-575-4505
  • Fax:
Mailing address:
  • Phone: 404-575-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018533
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: