Provider Demographics
NPI:1710647631
Name:DUTEAU, JOHN BRIAN (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRIAN
Last Name:DUTEAU
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 2417
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-2417
Mailing Address - Country:US
Mailing Address - Phone:770-282-8820
Mailing Address - Fax:
Practice Address - Street 1:200 W ACADEMY ST NW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-8568
Practice Address - Country:US
Practice Address - Phone:770-282-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant