Basic Information
Provider Information | |||||||||
NPI: | 1306328323 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARIANO-SABIDO | ||||||||
FirstName: | ANTOINETTE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 206 BLACK HAWKE LN | ||||||||
Address2: |   | ||||||||
City: | KATHLEEN | ||||||||
State: | GA | ||||||||
PostalCode: | 310471405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023210878 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 350 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312173838 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787657000 | ||||||||
FaxNumber: | 7123225730 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2018 | ||||||||
LastUpdateDate: | 09/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 093289 | IA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 9229 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.