MEDICARE: VASSILAKIS VASSILIOU PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	004684	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295826105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VASSILAKIS VASSILIOU PA-C

Provider Business Mailing Address
First Line	:	55 WHITCHER STREET
Second Line	:	SUITE 350
City	:	MARIETTA
State	:	GA
Zip	:	30060-1129
Country	:	US
Telephone Number	:	770-424-6893
Fax Number	:

Provider Business Practice Location Address
First Line	:	460 NORTHSIDE CHEROKEE BLVD STE 130
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-8017
Country	:	US
Telephone Number	:	678-493-2527
Fax Number	:	678-593-5608

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	01/05/2018

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Directions to “ VASSILAKIS VASSILIOU PA-C” Practice Location

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