Provider Demographics
NPI:1376918656
Name:FORD, GREGORY (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:FORD
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 1:3278 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-5820
Mailing Address - Fax:
Practice Address - Street 1:3278 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-1500
Practice Address - Country:US
Practice Address - Phone:229-257-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant