Provider Demographics
NPI:1265830152
Name:PUCKETT, BRETT DANIEL (PA-C, MMSC, ATC)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:DANIEL
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:PA-C, MMSC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CIRCLE 75 PKWY SE STE 1700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3087
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:771 OLD NORCROSS RD STE 390
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4324
Practice Address - Country:US
Practice Address - Phone:678-957-0757
Practice Address - Fax:678-957-9597
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002274A2255A2300X
390200000X
GA10254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program