Provider Demographics
NPI:1669435707
Name:GWAN-NULLA, MEESHA B (MD)
Entity type:Individual
Prefix:
First Name:MEESHA
Middle Name:B
Last Name:GWAN-NULLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:16 PHYSICIAN DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-8486
Mailing Address - Country:US
Mailing Address - Phone:828-456-9836
Mailing Address - Fax:828-452-9814
Practice Address - Street 1:2737 WARM SPRINGS RD BLDG BC
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6859
Practice Address - Country:US
Practice Address - Phone:706-653-2255
Practice Address - Fax:706-653-2329
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2015-01372207R00000X
MO2009028452207R00000X
PAMD064633L207R00000X
GA081189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCO942D811Medicare PIN
G96530Medicare UPIN
G96530Medicare UPIN
MO137710003OtherMEDICARE INDIVDUAL