Provider Demographics
NPI:1972117919
Name:ZIMMERMAN, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 N E EXPY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4003
Mailing Address - Country:US
Mailing Address - Phone:404-408-9330
Mailing Address - Fax:
Practice Address - Street 1:2669 FLEUR DE LIS PL
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30360-1409
Practice Address - Country:US
Practice Address - Phone:321-960-1383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10245OtherGA MEDICAL BOARD