Provider Demographics
NPI:1700030624
Name:POODIACK, KATHY S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:S
Last Name:POODIACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:S
Other - Last Name:ACKERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 HOSPITAL SOUTH DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8116
Mailing Address - Country:US
Mailing Address - Phone:770-944-2830
Mailing Address - Fax:678-581-7170
Practice Address - Street 1:1700 HOSPITAL SOUTH DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8116
Practice Address - Country:US
Practice Address - Phone:770-944-2830
Practice Address - Fax:678-581-7170
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002325OtherSTATE MEDICAL LICENSE
GAGRP245OtherMEDICARE, GROUP NUMBER