Healthcare Provider Details

I. General information

NPI: 1477073633
Provider Name (Legal Business Name): JAMES MATTHEW LOUTZENHISER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 02/11/2024
Certification Date: 02/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD STE 170
ATLANTA GA
30342-1607
US

IV. Provider business mailing address

980 JOHNSON FERRY RD STE 170
ATLANTA GA
30342-1607
US

V. Phone/Fax

Practice location:
  • Phone: 404-300-2140
  • Fax: 404-300-2240
Mailing address:
  • Phone: 404-300-2140
  • Fax: 404-300-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8371
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8371
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: