Provider Demographics
NPI:1487646287
Name:KLOSKY, AMANDA KATHRYN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KATHRYN
Last Name:KLOSKY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ORTHO LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2315
Mailing Address - Country:US
Mailing Address - Phone:404-778-3350
Mailing Address - Fax:
Practice Address - Street 1:21 ORTHO LN
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2315
Practice Address - Country:US
Practice Address - Phone:404-778-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3264363AM0700X, 363AS0400X
GA003264364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000985AMedicaid
GA97BBDPSMedicare ID - Type Unspecified