Healthcare Provider Details

I. General information

NPI: 1154530756
Provider Name (Legal Business Name): KYMBERLY M TART PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MT HIGHWAY 91 S
DILLON MT
59725-7379
US

IV. Provider business mailing address

601 S. ENOTA DRIVE SUITE Q
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 406-683-3000
  • Fax:
Mailing address:
  • Phone: 770-533-8420
  • Fax: 770-533-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004137
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: