Healthcare Provider Details

I. General information

NPI: 1003803354
Provider Name (Legal Business Name): MISHANA L. MOGELNICKI PAAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD NE
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

3155 N POINT PKWY ATTN: CREDENTIALING DEPT, BUILDING F, SUITE 100
ALPHARETTA GA
30005
US

V. Phone/Fax

Practice location:
  • Phone: 770-645-9181
  • Fax: 770-645-8455
Mailing address:
  • Phone: 770-645-9181
  • Fax: 770-645-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2478
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: