Provider Demographics
NPI:1740769132
Name:BOCCUCCI, KRISTINA POSS (PA)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:POSS
Last Name:BOCCUCCI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 WAYLON DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1346
Mailing Address - Country:US
Mailing Address - Phone:404-909-1220
Mailing Address - Fax:
Practice Address - Street 1:1305 JENNINGS MILL RD BLDG 300-110
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7238
Practice Address - Country:US
Practice Address - Phone:706-613-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12550207X00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery