Provider Demographics
NPI:1174026033
Name:KILGORE, KORTNI (PA)
Entity Type:Individual
Prefix:
First Name:KORTNI
Middle Name:
Last Name:KILGORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 PERMIAN WAY STE D
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3226
Mailing Address - Country:US
Mailing Address - Phone:770-627-7246
Mailing Address - Fax:
Practice Address - Street 1:403 PERMIAN WAY STE D
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3226
Practice Address - Country:US
Practice Address - Phone:770-627-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant