Provider Demographics
NPI:1073960118
Name:BOOTH, MALLORY A (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:BOOTH
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 1:800 1ST ST STE 410
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8306
Mailing Address - Country:US
Mailing Address - Phone:478-743-7068
Mailing Address - Fax:478-741-1354
Practice Address - Street 1:800 1ST ST STE 410
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8306
Practice Address - Country:US
Practice Address - Phone:478-743-7068
Practice Address - Fax:478-741-1354
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical