Provider Demographics
NPI:1447464243
Name:MAIKI, VIMLA R (PA)
Entity type:Individual
Prefix:
First Name:VIMLA
Middle Name:R
Last Name:MAIKI
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 1:101 W PONCE DELEON
Mailing Address - Street 2:ROOM 331
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2542
Mailing Address - Country:US
Mailing Address - Phone:404-778-5000
Mailing Address - Fax:
Practice Address - Street 1:830 EAGLES LANDING PARKWAY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7366
Practice Address - Country:US
Practice Address - Phone:404-778-6886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004352363AM0700X, 363A00000X
GA4352363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS37405Medicare UPIN