Healthcare Provider Details

I. General information

NPI: 1215148382
Provider Name (Legal Business Name): MARY HARLOS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30045-7694
US

IV. Provider business mailing address

2285 HARBIN OAKS DR
DACULA GA
30019-2389
US

V. Phone/Fax

Practice location:
  • Phone: 678-442-3317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3834
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: