Provider Demographics
NPI:1730431313
Name:LAU, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:LAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 RIDGEMONT LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4049
Mailing Address - Country:US
Mailing Address - Phone:678-232-4463
Mailing Address - Fax:
Practice Address - Street 1:2801 N. DECATUR ROAD SUITE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-719-4219
Practice Address - Fax:404-719-4231
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant