Healthcare Provider Details

I. General information

NPI: 1710952387
Provider Name (Legal Business Name): KIMBERLY GORE-GRIFFIN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KIMBERLY YVETTE GORE PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

868 YORK AVE SW
ATLANTA GA
30310-2750
US

IV. Provider business mailing address

3893 LEPRECHAUN CT
DECATUR GA
30034-2169
US

V. Phone/Fax

Practice location:
  • Phone: 404-752-1438
  • Fax: 404-756-6870
Mailing address:
  • Phone: 404-752-1438
  • Fax: 404-756-6870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003459
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: