Provider Demographics
NPI:1063520237
Name:PETTIGNANO, MARY MERCEDES (AA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MERCEDES
Last Name:PETTIGNANO
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 BUCKHEAD AVE NE
Mailing Address - Street 2:1404
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2672
Mailing Address - Country:US
Mailing Address - Phone:404-983-0092
Mailing Address - Fax:
Practice Address - Street 1:5730 GLENRIDGE
Practice Address - Street 2:SUITE 300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:404-250-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002574363AM0700X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA367H00000XOtherANESTHETIST