Provider Demographics
NPI:1285993105
Name:RAU, MARY K (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:RAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 APPLING CT NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2542
Mailing Address - Country:US
Mailing Address - Phone:770-369-7892
Mailing Address - Fax:
Practice Address - Street 1:49 HOSIERY MILL RD
Practice Address - Street 2:124
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-1687
Practice Address - Country:US
Practice Address - Phone:770-443-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-12
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
GA006452363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical