Basic Information
| Provider Information | |||||||||
| NPI: | 1730430893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTOSH | ||||||||
| FirstName: | NINEVEH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAWSON | ||||||||
| OtherFirstName: | NINEVEH | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 746638 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 ARDISIA LANE | ||||||||
| Address2: | |||||||||
| City: | ST. JOHNS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042872794 | ||||||||
| FaxNumber: | 9043907458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9106841 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA9106841 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.