Provider Demographics
NPI:1841462538
Name:PRATER, RICHARD BRIAN (PA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:BRIAN
Last Name:PRATER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:270 CHASTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3012
Mailing Address - Country:US
Mailing Address - Phone:770-421-8005
Mailing Address - Fax:770-424-5662
Practice Address - Street 1:270 CHASTAIN RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3012
Practice Address - Country:US
Practice Address - Phone:770-421-8005
Practice Address - Fax:770-424-5662
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA005499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA442741884BMedicaid
GA442741884AMedicaid
GA511I970628Medicare PIN