Basic Information
| Provider Information | |||||||||
| NPI: | 1699100073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATTAM | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | KURUVILLA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1565 FOREST BROOK TRL | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300418132 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 705 JESSE JEWELL PKWY SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705349014 | ||||||||
| FaxNumber: | 7705349012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2013 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.