Provider Demographics
NPI:1922555036
Name:SANDERS, KAITLYN MIKAELA (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MIKAELA
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:MIKAELA
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3905 JOHNS CREEK COURT COMPREHENSIVE PRIMARY CARE, LLC
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:678-888-2273
Mailing Address - Fax:314-516-5988
Practice Address - Street 1:761 WALTHER ROAD COMPREHENSIVE PRIMARY CARE, LLC
Practice Address - Street 2:SUITE 200
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:678-888-2273
Practice Address - Fax:678-888-2273
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11772363A00000X
MO2017018663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100443760Medicaid
KYK214480Medicare PIN