Provider Demographics
NPI:1427662964
Name:MONGO, AUTUMN WALTON (PA-C)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:WALTON
Last Name:MONGO
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1451 HIGHWAY 21 S STE H
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-5244
Mailing Address - Country:US
Mailing Address - Phone:912-754-1035
Mailing Address - Fax:912-754-1037
Practice Address - Street 1:1451 HIGHWAY 21 S STE H
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:GA
Practice Address - Zip Code:31329-5244
Practice Address - Country:US
Practice Address - Phone:912-754-1035
Practice Address - Fax:912-754-1037
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2024-11-06
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant