Healthcare Provider Details

I. General information

NPI: 1063520237
Provider Name (Legal Business Name): MARY MERCEDES PETTIGNANO A.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 GLENRIDGE SUITE 300
ATLANTA GA
30328
US

IV. Provider business mailing address

298 BUCKHEAD AVE NE 1404
ATLANTA GA
30305-2672
US

V. Phone/Fax

Practice location:
  • Phone: 404-250-1153
  • Fax:
Mailing address:
  • Phone: 404-983-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002574
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number002574
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: