Provider Demographics
NPI:1639877954
Name:ANTONOWICH, ELIZA MATTSON (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:MATTSON
Last Name:ANTONOWICH
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 GALLATREE LN
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-1218
Mailing Address - Country:US
Mailing Address - Phone:678-654-0681
Mailing Address - Fax:
Practice Address - Street 1:595 HURRICANE SHOALS RD NW STE 300
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8762
Practice Address - Country:US
Practice Address - Phone:770-995-0823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN318173363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics