1780775486 NPI number — BENITA NANNETTE HAMILTON PA-C

Table of content: BENITA NANNETTE HAMILTON PA-C (NPI 1780775486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780775486 NPI number — BENITA NANNETTE HAMILTON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMILTON
Provider First Name:
BENITA
Provider Middle Name:
NANNETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780775486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4764 SPRUCE WAY SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH FULTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30331-7540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-551-4229
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 NATHAN DEAN BLVD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30157-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-624-6792
Provider Business Practice Location Address Fax Number:
470-202-1026
Provider Enumeration Date:
09/27/2006

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: 363A00000X , with the licence number:  005769-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 12130 , 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)

  • Identifier: 00355931 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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