Provider Demographics
NPI:1710952387
Name:GORE-GRIFFIN, KIMBERLY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:GORE-GRIFFIN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:YVETTE
Other - Last Name:GORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:3893 LEPRECHAUN CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-2169
Mailing Address - Country:US
Mailing Address - Phone:404-752-1438
Mailing Address - Fax:404-756-6870
Practice Address - Street 1:868 YORK AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-2750
Practice Address - Country:US
Practice Address - Phone:404-752-1438
Practice Address - Fax:404-756-6870
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003459363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical