Healthcare Provider Details

I. General information

NPI: 1194208132
Provider Name (Legal Business Name): PAMELA VAN GUTWEIN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA CHI PAC

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11685 ALPHARETTA HWY STE 170
ROSWELL GA
30076-4913
US

IV. Provider business mailing address

11685 ALPHARETTA HWY STE 170
ROSWELL GA
30076-4913
US

V. Phone/Fax

Practice location:
  • Phone: 770-619-0004
  • Fax: 770-619-0252
Mailing address:
  • Phone: 770-619-0004
  • Fax: 770-619-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8903
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: