Basic Information
| Provider Information | |||||||||
| NPI: | 1447464243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAIKI | ||||||||
| FirstName: | VIMLA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W PONCE DELEON | ||||||||
| Address2: | ROOM 331 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300302542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047785000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 830 EAGLES LANDING PARKWAY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302817366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786886 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
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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 | 363AM0700X | 004352 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 4352 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 004352 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.