Healthcare Provider Details

I. General information

NPI: 1417452616
Provider Name (Legal Business Name): AK SURGICAL ASSISTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 02/01/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023 GRAYSON HWY STE 201
GRAYSON GA
30017-5047
US

IV. Provider business mailing address

2023 GRAYSON HWY STE 201
GRAYSON GA
30017-5047
US

V. Phone/Fax

Practice location:
  • Phone: 678-656-6819
  • Fax: 678-985-4855
Mailing address:
  • Phone: 770-978-1400
  • Fax: 678-656-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ANDREA M KENNEDY
Title or Position: CEO
Credential: CSFA
Phone: 678-656-6819