Provider Demographics
NPI:1326322918
Name:SANON, KATHLEEN KAPOLKA (PAAA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:KAPOLKA
Last Name:SANON
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:KAPOLKA, PARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAAA
Mailing Address - Street 1:1128 POWELL CT SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2602
Mailing Address - Country:US
Mailing Address - Phone:865-335-7978
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3050
Practice Address - Country:US
Practice Address - Phone:404-616-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-01
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011032949367H00000X
GA006785367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134569AMedicaid
GA202I326428Medicare PIN