Healthcare Provider Details

I. General information

NPI: 1609555630
Provider Name (Legal Business Name): BRIAN PATRICK KITTRELL CST, CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2537 CEDARCREST RD STE 305-14
ACWORTH GA
30101-8900
US

IV. Provider business mailing address

2537 CEDARCREST RD STE 305-14
ACWORTH GA
30101-8900
US

V. Phone/Fax

Practice location:
  • Phone: 470-336-8190
  • Fax: 770-336-6620
Mailing address:
  • Phone: 470-336-8190
  • Fax: 770-336-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number213054
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: