Basic Information
| Provider Information | |||||||||
| NPI: | 1629556832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | CHANDLER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1001 SUMMIT BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303196410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709891668 | ||||||||
| FaxNumber: | 6783881759 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 PHIIP BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708225560 | ||||||||
| FaxNumber: | 7708224989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008862 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003208377A | 05 | GA | MEDICAID |