Provider Demographics
NPI:1366007841
Name:HENRY, GAGE MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:GAGE
Middle Name:MATTHEW
Last Name:HENRY
Suffix:
Gender:M
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 1:4 E JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5895
Mailing Address - Country:US
Mailing Address - Phone:912-355-1010
Mailing Address - Fax:912-351-0579
Practice Address - Street 1:4 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5895
Practice Address - Country:US
Practice Address - Phone:912-355-1010
Practice Address - Fax:912-351-0579
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9247363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty