Basic Information
| Provider Information | |||||||||
| NPI: | 1194706234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | JACKSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | I | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709420457 | ||||||||
| FaxNumber: | 7709427699 | ||||||||
| Practice Location | |||||||||
| Address1: | 4586 TIMBER RIDGE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301357514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709420457 | ||||||||
| FaxNumber: | 7709427699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003791 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003101476B | 05 | GA | MEDICAID | 202I970546 | 01 | GA | MEDICARE PTAN | OTHER |