Provider Demographics
NPI:1538113840
Name:GENTRY, LARRY J (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:GENTRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-9117
Mailing Address - Country:US
Mailing Address - Phone:770-779-0015
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001373363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10041973OtherAMERIGROUP
GA333479OtherWELLCARE
GA100002611BMedicaid
GA100002611AMedicaid
GA100002611Medicaid
GA970021256Medicare PIN
GA97BBHBSMedicare ID - Type Unspecified
GA100002611BMedicaid
GA333479OtherWELLCARE