Healthcare Provider Details

I. General information

NPI: 1750165775
Provider Name (Legal Business Name): KISA MEREDITH PA-C, MHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOHNSON FY RD NE STE 335
ATLANTA GA
30342-1625
US

IV. Provider business mailing address

960 JOHNSON FY RD NE STE 335
ATLANTA GA
30342-1625
US

V. Phone/Fax

Practice location:
  • Phone: 404-497-8700
  • Fax:
Mailing address:
  • Phone: 404-497-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number11890
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11890
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: