Healthcare Provider Details

I. General information

NPI: 1215084959
Provider Name (Legal Business Name): DUANE L PRICKETT SA-C, RSA, LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1579 MONROE DR NE STE F
ATLANTA GA
30324-5022
US

IV. Provider business mailing address

1579 MONROE DR NE STE F UNIT 711
ATLANTA GA
30324-5022
US

V. Phone/Fax

Practice location:
  • Phone: 404-788-1321
  • Fax:
Mailing address:
  • Phone: 404-788-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number02-151
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: