MEDICARE: MRS. MEGHAN LYNN SUMMERALL P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	4843	GA

General Provider Information

NPI Number	:	1487664405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MEGHAN LYNN SUMMERALL P.A.

Provider Business Mailing Address
First Line	:	1000 PROFESSIONAL BLVD
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30045
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 PROFESSIONAL DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30045-7651
Country	:	US
Telephone Number	:	678-312-3317
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	09/26/2013

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