Healthcare Provider Details

I. General information

NPI: 1649350422
Provider Name (Legal Business Name): DEBRA ENGELKE MATTIS PAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBRA ENGELKE PAA

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FERRY RD SCOTTISH RITE DEPT OF ANES
ATLANTA GA
30342
US

IV. Provider business mailing address

1338 EDMUND PARK DRIVE
ATLANTA GA
30306
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-2008
  • Fax: 404-785-4496
Mailing address:
  • Phone: 404-875-5569
  • Fax: 404-785-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number003753
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: