Provider Demographics
NPI:1225085160
Name:KOBERNUS, MONA M (CRNA)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:M
Last Name:KOBERNUS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:140 THOMAS CREEK CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-2835
Mailing Address - Country:US
Mailing Address - Phone:678-319-0972
Mailing Address - Fax:678-319-0972
Practice Address - Street 1:6335 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1549
Practice Address - Country:US
Practice Address - Phone:404-778-8311
Practice Address - Fax:770-495-1585
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN037498367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000874013IMedicaid
R30025Medicare UPIN
GA43ZCBVW37Medicare ID - Type Unspecified