Provider Demographics
NPI:1164486817
Name:NOUGAISSE, JEAN GERALD (PA-C)
Entity type:Individual
Prefix:
First Name:JEAN GERALD
Middle Name:
Last Name:NOUGAISSE
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 1:2512 KELMAN PL
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7099
Mailing Address - Country:US
Mailing Address - Phone:770-277-2424
Mailing Address - Fax:770-277-2424
Practice Address - Street 1:3400 MCCLURE BRIDGE RD BLDG B
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6675
Practice Address - Country:US
Practice Address - Phone:678-957-8801
Practice Address - Fax:678-957-8804
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005668363AS0400X
GA004761207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ69515Medicare UPIN
NY6225LEZ521Medicare ID - Type Unspecified