Provider Demographics
NPI:1801066790
Name:GESITE, AL WYNNE QUERUBIN (PT)
Entity type:Individual
Prefix:
First Name:AL WYNNE
Middle Name:QUERUBIN
Last Name:GESITE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 WOODLAND LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-8725
Mailing Address - Country:US
Mailing Address - Phone:404-771-0554
Mailing Address - Fax:770-442-3490
Practice Address - Street 1:670 NORTH AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1100
Practice Address - Country:US
Practice Address - Phone:404-771-0554
Practice Address - Fax:770-442-3490
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist