Provider Demographics
NPI:1386628790
Name:SAMPLES, KATHRYN B (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:B
Last Name:SAMPLES
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 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:157 CLINIC AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4413
Practice Address - Country:US
Practice Address - Phone:770-834-3336
Practice Address - Fax:770-832-2136
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003055363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000202AMedicaid
GAD40883OtherBLUE CROSS
GA30117A006OtherCHAMPUS
GA97BBCVPMedicare ID - Type Unspecified