Provider Demographics
NPI:1851371371
Name:SPRAGUE, PATSY
Entity Type:Individual
Prefix:
First Name:PATSY
Middle Name:
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 KLINE CIR
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-5128
Mailing Address - Country:US
Mailing Address - Phone:770-228-7790
Mailing Address - Fax:770-478-2908
Practice Address - Street 1:405 ARROWHEAD BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1254
Practice Address - Country:US
Practice Address - Phone:770-478-9877
Practice Address - Fax:770-478-2908
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR030904367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00560172AMedicaid
GAR12411Medicare UPIN
GA00560172AMedicaid