Healthcare Provider Details

I. General information

NPI: 1740769132
Provider Name (Legal Business Name): KRISTINA POSS BOCCUCCI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 JENNINGS MILL RD BLDG 300-110
WATKINSVILLE GA
30677-7238
US

IV. Provider business mailing address

4234 WAYLON DR
MARTINEZ GA
30907-1346
US

V. Phone/Fax

Practice location:
  • Phone: 706-613-5880
  • Fax:
Mailing address:
  • Phone: 404-909-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12550
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number12550
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: