Basic Information
| Provider Information | |||||||||
| NPI: | 1225097124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISOM | ||||||||
| FirstName: | AMINA | ||||||||
| MiddleName: | JACKSON | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | AMINA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 740209 | ||||||||
| Address2: | DEPT 1029 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303740209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413601566 | ||||||||
| FaxNumber: | 9413589818 | ||||||||
| Practice Location | |||||||||
| Address1: | 5671 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 680 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047056985 | ||||||||
| FaxNumber: | 4048519950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 12/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN063448 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000556795 | 05 | GA | MEDICAID |