Provider Demographics
NPI:1578619219
Name:STOUT, MANDY C (PA-C)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:C
Last Name:STOUT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:755 WALTHER RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8725
Mailing Address - Country:US
Mailing Address - Phone:770-962-0399
Mailing Address - Fax:678-252-3722
Practice Address - Street 1:1700 TREE LN
Practice Address - Street 2:SUITE 170
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6782
Practice Address - Country:US
Practice Address - Phone:770-962-0399
Practice Address - Fax:678-252-3722
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003919363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
97WCJLSMedicare PIN
P86484Medicare UPIN
97WCGRGMedicare ID - Type Unspecified