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General NPI Number Information
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NPI Number | 1881723682
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Entity Type | Individual
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Provider Name | BETH ANN PENDERGRAPH P.A.
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Gender | Female
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 01/24/2012
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Provider Practice Location Address
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Address Line | 1805 VERNON RD SUITE B
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City | LAGRANGE
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State | GA
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Zip | 30240-3871
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Country | US
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Telephone | 706-884-2691
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Fax | 706-845-7314
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Provider Business Mailing Address
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Address Line | 127 COVE HOLLOW RD
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City | FORTSON
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State | GA
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Zip | 31808-4353
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Country | US
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Telephone | 678-462-1977
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0048DO
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License Number State | GA
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