Provider Demographics
NPI:1336491711
Name:OSBORNE, MARY MALISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MALISSA
Last Name:OSBORNE
Suffix:
Gender:F
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8722
Mailing Address - Fax:
Practice Address - Street 1:1315 JESSE JEWELL PKWY NE STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3822
Practice Address - Country:US
Practice Address - Phone:770-219-9300
Practice Address - Fax:770-219-9301
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006618363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant