Provider Demographics
NPI:1861048787
Name:FORTUNE, TASIA (PA)
Entity type:Individual
Prefix:MRS
First Name:TASIA
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 HOSPITAL BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-0001
Mailing Address - Country:US
Mailing Address - Phone:770-410-4520
Mailing Address - Fax:770-410-4525
Practice Address - Street 1:4500 HOSPITAL BLVD STE 320
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-0001
Practice Address - Country:US
Practice Address - Phone:770-410-4520
Practice Address - Fax:770-410-4525
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3607363A00000X
390200000X
GA11303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4455PAMedicaid