Provider Demographics
NPI:1649350422
Name:MATTIS, DEBRA ENGELKE (PAA)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:ENGELKE
Last Name:MATTIS
Suffix:
Gender:F
Credentials:PAA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:ENGELKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAA
Mailing Address - Street 1:1338 EDMUND PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306
Mailing Address - Country:US
Mailing Address - Phone:404-875-5569
Mailing Address - Fax:404-785-4496
Practice Address - Street 1:1001 JOHNSON FERRY RD
Practice Address - Street 2:SCOTTISH RITE DEPT OF ANES
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-785-2008
Practice Address - Fax:404-785-4496
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003753367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA32BBBTJMedicare ID - Type Unspecified