Healthcare Provider Details

I. General information

NPI: 1265830152
Provider Name (Legal Business Name): BRETT DANIEL PUCKETT PA-C, MMSC, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 11/15/2022
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 OLD NORCROSS RD STE 390
LAWRENCEVILLE GA
30046-4324
US

IV. Provider business mailing address

900 CIRCLE 75 PKWY SE STE 1700
ATLANTA GA
30339-3087
US

V. Phone/Fax

Practice location:
  • Phone: 678-957-0757
  • Fax: 678-957-9597
Mailing address:
  • Phone: 770-953-6929
  • Fax: 770-953-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002274A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10254
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: