=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629553383
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEASIA DIAZ HENDERSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2018
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 JOHNSON FERRY RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-785-2273
-----------------------------------------------------
Fax | 404-785-9168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11350 MCCORMICK ROAD EP1, SUITE 501
-----------------------------------------------------
City | HUNT VALLEY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-329-1071
-----------------------------------------------------
Fax | 410-329-1054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | C0006922
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10810
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------