Healthcare Provider Details

I. General information

NPI: 1154870491
Provider Name (Legal Business Name): PATRICK R GAMBLIN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 13TH ST SUITE 20
AUGUSTA GA
30901-2700
US

IV. Provider business mailing address

811 13TH ST SUITE 20
AUGUSTA GA
30901-2700
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-3401
  • Fax: 706-724-6540
Mailing address:
  • Phone: 706-722-3401
  • Fax: 706-724-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8143
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: