Healthcare Provider Details

I. General information

NPI: 1487119004
Provider Name (Legal Business Name): HEE KANG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PETER HEE-HOON KANG PA

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1476
US

IV. Provider business mailing address

2552 AMELIA AVE
DECATUR GA
30032-3212
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-4747
  • Fax:
Mailing address:
  • Phone: 404-547-0558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9172
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: