Basic Information
| Provider Information | |||||||||
| NPI: | 1225085160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOBERNUS | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 THOMAS CREEK CT | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300042835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783190972 | ||||||||
| FaxNumber: | 6783190972 | ||||||||
| Practice Location | |||||||||
| Address1: | 6335 HOSPITAL PKWY | ||||||||
| Address2: | |||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300971549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047788311 | ||||||||
| FaxNumber: | 7704951585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN037498 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000874013I | 05 | GA | MEDICAID |