Provider Demographics
NPI:1437799285
Name:MCCAULEY, MARY LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAUREN
Last Name:MCCAULEY
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:200 S ENOTA DR NE STE 380
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3475
Practice Address - Country:US
Practice Address - Phone:770-219-7099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11140OtherGEORGIA MEDICAL COMPOSITE BOARD
1169725OtherNCCPA ID