Healthcare Provider Details

I. General information

NPI: 1396274007
Provider Name (Legal Business Name): KATHERINE MICHELLE GUDGER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 MERIDIAN MARK RD STE 570
ATLANTA GA
30342-2807
US

IV. Provider business mailing address

5461 MERIDIAN MARK RD STE 570
ATLANTA GA
30342-2807
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-6895
  • Fax: 404-785-6896
Mailing address:
  • Phone: 404-785-6895
  • Fax: 404-785-6896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8402
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: