Basic Information
| Provider Information | |||||||||
| NPI: | 1649350422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTIS | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | ENGELKE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PAA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ENGELKE | ||||||||
| OtherFirstName: | DEBRA | ||||||||
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| OtherCredential: | PAA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1338 EDMUND PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048755569 | ||||||||
| FaxNumber: | 4047854496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 JOHNSON FERRY RD | ||||||||
| Address2: | SCOTTISH RITE DEPT OF ANES | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047852008 | ||||||||
| FaxNumber: | 4047854496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 003753 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.