Provider Demographics
NPI:1457453482
Name:MCPETERS, JIMMY M (PAC)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:M
Last Name:MCPETERS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 PROFESSIONAL DR
Mailing Address - Street 2:SUITE #510
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3333
Mailing Address - Country:US
Mailing Address - Phone:770-670-4270
Mailing Address - Fax:
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:SUITE #510
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3333
Practice Address - Country:US
Practice Address - Phone:770-670-4270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q30522Medicare UPIN
Q30522Medicare UPIN