Provider Demographics
NPI:1083852016
Name:BAUMAN, KATHRYN JALAL
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:JALAL
Last Name:BAUMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:JALAL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:162 MEAD RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3621
Mailing Address - Country:US
Mailing Address - Phone:919-636-2709
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:919-636-2709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant