Basic Information
| Provider Information | |||||||||
| NPI: | 1902871445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUTKA | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15385 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277040385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194775152 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 DAN PROCTOR DR | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315583810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124667000 | ||||||||
| FaxNumber: | 9194775470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 08/06/2008 | ||||||||
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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 | 363AM0700X | 004291 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 256737965A | 05 | GA | MEDICAID | 01157750 | 01 | GA | AMERIGROUP | OTHER | 256737965D | 05 | GA | MEDICAID | 256737965C | 05 | GA | MEDICAID |