Healthcare Provider Details

I. General information

NPI: 1295424125
Provider Name (Legal Business Name): ADAM M KHANU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 ELM ST
CUMMING GA
30040-2467
US

IV. Provider business mailing address

260 ELM ST
CUMMING GA
30040-2467
US

V. Phone/Fax

Practice location:
  • Phone: 470-758-8573
  • Fax:
Mailing address:
  • Phone: 470-758-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: