Provider Demographics
NPI:1336637024
Name:STORY, SERA GABRIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:SERA
Middle Name:GABRIELLE
Last Name:STORY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3110
Mailing Address - Country:US
Mailing Address - Phone:478-237-9928
Mailing Address - Fax:
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401
Practice Address - Country:US
Practice Address - Phone:478-237-9928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008762363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA008762OtherGA PA LICENSE
GA003205741Medicaid
GAMS4799841OtherDEA LICENSE