Provider Demographics
NPI:1750320685
Name:MERCEDAT, JERRY U (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:U
Last Name:MERCEDAT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:631 PROFESSIONAL DR STE 170
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3392
Practice Address - Country:US
Practice Address - Phone:678-312-2663
Practice Address - Fax:770-962-8587
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA860522900FMedicaid
GA511I970623Medicare PIN
GA860522900FMedicaid