1710952387 NPI number — MRS. KIMBERLY GORE-GRIFFIN PHYSICIAN ASSISTANT

Table of content: MRS. KIMBERLY GORE-GRIFFIN PHYSICIAN ASSISTANT (NPI 1710952387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710952387 NPI number — MRS. KIMBERLY GORE-GRIFFIN PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORE-GRIFFIN
Provider First Name:
KIMBERLY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GORE
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
YVETTE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710952387
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:
3893 LEPRECHAUN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30034-2169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-752-1438
Provider Business Mailing Address Fax Number:
404-756-6870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
868 YORK AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30310-2750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-752-1438
Provider Business Practice Location Address Fax Number:
404-756-6870
Provider Enumeration Date:
02/17/2006

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: 363AM0700X , with the licence number:  003459 , 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)