Basic Information
| Provider Information | |||||||||
| NPI: | 1619092756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAGER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | |||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972810 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | |||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 06/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | RAG104267909 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | RAG104267909 | 01 | GA | NCC WHNP LICENSE | OTHER | RN061422NP | 01 | GA | NP LICENSE | OTHER |