Healthcare Provider Details

I. General information

NPI: 1043831449
Provider Name (Legal Business Name): KABRIEL MOOREHEAD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 NORTHSIDE DR NW APT 2421
ATLANTA GA
30318-1837
US

IV. Provider business mailing address

1390 NORTHSIDE DR NW APT 2421
ATLANTA GA
30318-1837
US

V. Phone/Fax

Practice location:
  • Phone: 904-318-7009
  • Fax:
Mailing address:
  • Phone: 904-318-7009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10832
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: