Provider Demographics
NPI:1861798498
Name:THOMAS, LA TANYA YOUNG
Entity type:Individual
Prefix:
First Name:LA TANYA
Middle Name:YOUNG
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LA TANYA
Other - Middle Name:JERLINE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 993
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30085-0993
Mailing Address - Country:US
Mailing Address - Phone:404-429-3100
Mailing Address - Fax:
Practice Address - Street 1:555 SUN VALLEY DR
Practice Address - Street 2:SUITE G1
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5612
Practice Address - Country:US
Practice Address - Phone:770-717-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-29
Last Update Date:2011-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant