Provider Demographics
NPI:1184236598
Name:GRABOWSKI, KEITH (PA-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GRABOWSKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 OLD WHITE OAK TRL
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6353
Mailing Address - Country:US
Mailing Address - Phone:770-780-0784
Mailing Address - Fax:
Practice Address - Street 1:4205 MUNDY MILL PL
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2566
Practice Address - Country:US
Practice Address - Phone:770-532-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3633121300OtherNATIONAL REGISTRY OF CERTIFIED MEDICAL EXAMINERS
GA9756OtherGEORGIA COMPOSITE MEDICAL BOARD PHYSICIAN ASSISTANT LICENSE