Healthcare Provider Details

I. General information

NPI: 1437329950
Provider Name (Legal Business Name): HOLLY E GOSSETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax:
Mailing address:
  • Phone: 770-424-6893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104509
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06470
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009245
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: