Healthcare Provider Details

I. General information

NPI: 1124046867
Provider Name (Legal Business Name): THOMAS E STAUTER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

PO BOX 2938
GAINESVILLE GA
30503-2938
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-2146
  • Fax: 770-536-7895
Mailing address:
  • Phone: 770-536-2146
  • Fax: 770-536-7895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000954
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: