Provider Demographics
NPI:1306985619
Name:MACERA, TANA M (ANP-BC)
Entity type:Individual
Prefix:
First Name:TANA
Middle Name:M
Last Name:MACERA
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 0070
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-0070
Mailing Address - Country:US
Mailing Address - Phone:229-433-1000
Mailing Address - Fax:229-259-4405
Practice Address - Street 1:2501 N. PATTERSON STREET
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-433-1000
Practice Address - Fax:229-259-4405
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN127219NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA504617020BMedicaid
GA504617020BMedicaid
GA202I504326Medicare PIN