Healthcare Provider Details

I. General information

NPI: 1346656980
Provider Name (Legal Business Name): CATHERINE ANN CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 JESSE JEWELL PKWY NE
GAINESVILLE GA
30501-3822
US

IV. Provider business mailing address

1315 JESSE JEWELL PKWY NE
GAINESVILLE GA
30501-3822
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-6520
  • Fax:
Mailing address:
  • Phone:
  • 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 Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: