Provider Demographics
NPI:1447358254
Name:BRONAUGH, DAVID NEIL (PAC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:NEIL
Last Name:BRONAUGH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 ROLAND MANOR DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-6512
Mailing Address - Country:US
Mailing Address - Phone:678-376-0525
Mailing Address - Fax:
Practice Address - Street 1:3163 TUCKER NORCROSS RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-2124
Practice Address - Country:US
Practice Address - Phone:770-939-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant