Healthcare Provider Details

I. General information

NPI: 1689128902
Provider Name (Legal Business Name): ELLIOT STOKES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 PEACHTREE INDUSTRIAL BLVD #4101
SUWANEE GA
30024-4539
US

IV. Provider business mailing address

1780 PEACHTREE PKWY STE 302
CUMMING GA
30041-6834
US

V. Phone/Fax

Practice location:
  • Phone: 770-831-5525
  • Fax:
Mailing address:
  • Phone: 770-772-1830
  • Fax: 470-253-8215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8170
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: