Provider Demographics
NPI:1306298674
Name:TAH, KRISHNA SUMEER (PA-C)
Entity type:Individual
Prefix:
First Name:KRISHNA
Middle Name:SUMEER
Last Name:TAH
Suffix:
Gender:F
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 1:2470 MOUNT ZION PKWY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2500
Mailing Address - Country:US
Mailing Address - Phone:404-365-0966
Mailing Address - Fax:
Practice Address - Street 1:2470 MOUNT ZION PKWY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2500
Practice Address - Country:US
Practice Address - Phone:404-365-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306298674Medicaid