Provider Demographics
NPI:1417092248
Name:CAMPBELL, KIA D (PA)
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:D
Last Name:CAMPBELL
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:PO BOX 102321
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 HOWELL MILL RD NW STE LL10
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2593
Practice Address - Country:US
Practice Address - Phone:404-425-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003563363A00000X
GA35632085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003138520AMedicaid
GA202I977695Medicare PIN