Provider Demographics
NPI:1215084959
Name:PRICKETT, DUANE L (SA-C, RSA, LSA)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:L
Last Name:PRICKETT
Suffix:
Gender:M
Credentials:SA-C, RSA, LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1579 MONROE DR NE STE F
Mailing Address - Street 2:UNIT 711
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5022
Mailing Address - Country:US
Mailing Address - Phone:404-788-1321
Mailing Address - Fax:
Practice Address - Street 1:1579 MONROE DR NE STE F
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-5022
Practice Address - Country:US
Practice Address - Phone:404-788-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA02-151246ZC0007X
GA363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
02-151OtherSURGICAL ASSISTANT-CERTIFIED
IL238.000307OtherREGISTRATION
COSA.0001689OtherCOLORADO STATE LICENSE