Provider Demographics
NPI:1508379090
Name:SIROR, MARY C (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:SIROR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:478-745-6130
Mailing Address - Fax:478-478-7454
Practice Address - Street 1:308 COLISEUM DR STE 120
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3859
Practice Address - Country:US
Practice Address - Phone:478-745-6130
Practice Address - Fax:478-745-4443
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN160662363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG20164AOtherMEDICARE PTAN
GA003232245AMedicaid