MEDICARE: ETHAN EMORY PERKINS AGACNP-BC

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	363LA2100X	Acute Care Nurse Practitioner	RN280873	GA

General Provider Information

NPI Number	:	1780204701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN EMORY PERKINS AGACNP-BC

Provider Business Mailing Address
First Line	:	4142 MILL ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-2540
Country	:	US
Telephone Number	:	770-787-3550
Fax Number	:

Provider Business Practice Location Address
First Line	:	4142 MILL ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-2540
Country	:	US
Telephone Number	:	770-787-3550
Fax Number	:

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

Provider Enumeration Date	:	04/20/2020
Last Update Date	:	02/02/2022

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