Provider Demographics
NPI:1902871445
Name:DUTKA, GARY M (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:DUTKA
Suffix:
Gender:M
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:PO BOX 15385
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0385
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:2000 DAN PROCTOR DR
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3810
Practice Address - Country:US
Practice Address - Phone:912-466-7000
Practice Address - Fax:919-477-5470
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004291363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA256737965AMedicaid
GA01157750OtherAMERIGROUP
GA256737965DMedicaid
GA256737965CMedicaid
GA256737965CMedicaid
GAP00458581Medicare PIN
GA511I970135Medicare PIN
GA01157750OtherAMERIGROUP