Healthcare Provider Details

I. General information

NPI: 1396440152
Provider Name (Legal Business Name): CONNOR GUST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

V. Phone/Fax

Practice location:
  • Phone: 770-786-7053
  • Fax:
Mailing address:
  • Phone: 770-786-7053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number113388
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: