Healthcare Provider Details

I. General information

NPI: 1912607888
Provider Name (Legal Business Name): MATTHEW TRAWICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 CHATTAHOOCHEE RUN DR
SUWANEE GA
30024-8362
US

IV. Provider business mailing address

1870 CHATTAHOOCHEE RUN DR
SUWANEE GA
30024-8362
US

V. Phone/Fax

Practice location:
  • Phone: 678-333-8677
  • Fax:
Mailing address:
  • Phone: 678-333-8677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11785
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1912607888
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: