1366533986 NPI number — MRS. KIM DENISE LATTIMORE PA-C

Table of content: MRS. KIM DENISE LATTIMORE PA-C (NPI 1366533986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366533986 NPI number — MRS. KIM DENISE LATTIMORE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATTIMORE
Provider First Name:
KIM
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LATTIMORE
Provider Other First Name:
KIM
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366533986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7000 FELDSPAR CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31909-2212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-507-1185
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7950 MARTIN LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BENNING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31905-5647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-573-9363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  4741 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com