Healthcare Provider Details

I. General information

NPI: 1750497343
Provider Name (Legal Business Name): MARA B EHRET PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1388 A WELLBROOK CIRCLE
CONYERS GA
30012-3872
US

IV. Provider business mailing address

3390 PEACHTREE NERD 1500
ATLANTA GA
30326-2822
US

V. Phone/Fax

Practice location:
  • Phone: 770-929-9033
  • Fax: 770-929-9092
Mailing address:
  • Phone: 404-920-4972
  • Fax: 404-920-4959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003621
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: