Healthcare Provider Details

I. General information

NPI: 1750320685
Provider Name (Legal Business Name): JERRY U. MERCEDAT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR STE 170
LAWRENCEVILLE GA
30046-3392
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-2663
  • Fax: 770-962-8587
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004283
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: