Provider Demographics
NPI:1730535154
Name:GHANEM, KARIM MAMDOUH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KARIM
Middle Name:MAMDOUH
Last Name:GHANEM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 27
Mailing Address - Street 2:37 JONES STREET
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917
Mailing Address - Country:US
Mailing Address - Phone:919-621-3469
Mailing Address - Fax:
Practice Address - Street 1:5665 NEW NORTHSIDE DRIVE
Practice Address - Street 2:SUITE 320
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:770-874-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant