1073949475 NPI number — KWANIKA POMALES

Table of content: MRS. ANDREA MARY SLOAN M.D. (NPI 1053315325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073949475 NPI number — KWANIKA POMALES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POMALES
Provider First Name:
KWANIKA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073949475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/09/2015
NPI Reactivation Date:
10/07/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5425 SUGARLOAF PARKWAY
Provider Second Line Business Mailing Address:
SUITE 1101
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-697-5793
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5425 SUGARLOAF PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 1101
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-697-5793
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2013

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: 101YP2500X , with the licence number:  LPC006225 , 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)