Provider Demographics
NPI:1194208132
Name:GUTWEIN, PAMELA VAN (PAC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:VAN
Last Name:GUTWEIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:CHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:11685 ALPHARETTA HWY STE 170
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4913
Mailing Address - Country:US
Mailing Address - Phone:770-619-0004
Mailing Address - Fax:770-619-0252
Practice Address - Street 1:11685 ALPHARETTA HWY STE 170
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4913
Practice Address - Country:US
Practice Address - Phone:770-619-0004
Practice Address - Fax:770-619-0252
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8903363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical