Healthcare Provider Details

I. General information

NPI: 1295955441
Provider Name (Legal Business Name): KEVIN CLARK ROBERTSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 PEACHTREE RD NE STE 705
ATLANTA GA
30309-1476
US

IV. Provider business mailing address

2001 PEACHTREE RD NE STE 705
ATLANTA GA
30309-1476
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-0743
  • Fax: 855-273-3558
Mailing address:
  • Phone: 404-355-0743
  • Fax: 855-273-3558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17110
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10158
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: