Provider Demographics
NPI:1417092248
Name:CAMPBELL, KIA D (PA)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:D
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2001 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 645
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1476
Mailing Address - Country:US
Mailing Address - Phone:404-605-2050
Mailing Address - Fax:404-355-8421
Practice Address - Street 1:2001 PEACHTREE RD NE
Practice Address - Street 2:SUITE 645
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1476
Practice Address - Country:US
Practice Address - Phone:404-605-2050
Practice Address - Fax:404-355-8421
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA003563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003138520AMedicaid
GA202I977695Medicare PIN