Provider Demographics
NPI:1508899907
Name:LOCKETTE, PATRINA (MD)
Entity Type:Individual
Prefix:
First Name:PATRINA
Middle Name:
Last Name:LOCKETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRINA
Other - Middle Name:
Other - Last Name:LOCKETTE-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:807 S. ISABELLA ST.
Mailing Address - Street 2:PO BOX 545
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-0545
Mailing Address - Country:US
Mailing Address - Phone:229-777-4514
Mailing Address - Fax:229-776-7062
Practice Address - Street 1:354 E. WASHINGTON AVE.
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:GA
Practice Address - Zip Code:31714-5222
Practice Address - Country:US
Practice Address - Phone:229-567-3361
Practice Address - Fax:229-567-4083
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000876686FMedicaid
GA000876686GMedicaid
GA000876686GMedicaid
GA000876686FMedicaid