1619043650 NPI number — MS. SABRINA JACKSON BOTTS MMSC., PA-C

Table of content: MS. SABRINA JACKSON BOTTS MMSC., PA-C (NPI 1619043650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619043650 NPI number — MS. SABRINA JACKSON BOTTS MMSC., PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTTS
Provider First Name:
SABRINA
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MMSC., PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
SABRINA
Provider Other Middle Name:
YVETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619043650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5310 KIRK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30349-5800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-907-5832
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 ROSWELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062-4782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-601-7810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  3103 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com