Provider Demographics
NPI:1346333531
Name:SUTTER, KORY (PA AA)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:
Last Name:SUTTER
Suffix:
Gender:M
Credentials:PA AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932925
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2925
Mailing Address - Country:US
Mailing Address - Phone:800-364-9216
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:303 PARKWAY DR NE
Practice Address - Street 2:PMB 404
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:404-265-4520
Practice Address - Fax:404-265-3894
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004888367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA460363393AMedicaid
P00353078OtherRAILROAD MEDICARE
$$$$$$$$$OtherCHAMPUS/TRICARE
GA1982637419Medicare UPIN
$$$$$$$$$OtherCHAMPUS/TRICARE
GA1346333531Medicare PIN
GA511I320010Medicare Oscar/Certification