Healthcare Provider Details

I. General information

NPI: 1114379757
Provider Name (Legal Business Name): MIRIAM ABOUELNASR GOMES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 STEVE REYNOLDS BLVD
DULUTH GA
30096-4506
US

IV. Provider business mailing address

3650 STEVE REYNOLDS BLVD
DULUTH GA
30096-4506
US

V. Phone/Fax

Practice location:
  • Phone: 404-365-0966
  • Fax:
Mailing address:
  • Phone: 404-365-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1133611
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: