MEDICARE: MS. CAROL E., GAINES CSA

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	363AS0400X	Surgical Physician Assistant	3014	GA

General Provider Information

NPI Number	:	1659575090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL E., GAINES CSA

Provider Business Mailing Address
First Line	:	1425 MORIAH TRCE
Second Line	:
City	:	AUBURN
State	:	GA
Zip	:	30011-9637
Country	:	US
Telephone Number	:	404-936-1378
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 MORIAH TRCE
Second Line	:
City	:	AUBURN
State	:	GA
Zip	:	30011-9637
Country	:	US
Telephone Number	:	404-936-1378
Fax Number	:

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

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	07/08/2007

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