Healthcare Provider Details

I. General information

NPI: 1407439920
Provider Name (Legal Business Name): NOBLE OGBU JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 09/19/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 GILMER ST SE
ATLANTA GA
30303
US

IV. Provider business mailing address

1517 ASHBROOKE TRCE
STONE MTN GA
30083-1306
US

V. Phone/Fax

Practice location:
  • Phone: 404-550-6044
  • Fax:
Mailing address:
  • Phone: 404-550-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number11463
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number11463
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: