Provider Demographics
NPI:1336108042
Name:PUCKETT, SARA DESHLAR (CRNA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:DESHLAR
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:DEPT 1029 PO BOX 740209
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0209
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:941-358-9818
Practice Address - Street 1:5671 PEACHTREE-DUNWOODY ROAD
Practice Address - Street 2:SUITE 680
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5014
Practice Address - Country:US
Practice Address - Phone:404-705-6985
Practice Address - Fax:404-851-9950
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN161366367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P79581Medicare UPIN
GA43ZCCCT02Medicare ID - Type Unspecified