Provider Demographics
NPI:1871570143
Name:CLAUSON, MARY J (FNP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:CLAUSON
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Gender:F
Credentials:FNP
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Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:THE SOUTHEAST PERMANENTE MEDICAL GROUP
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-551-4948
Mailing Address - Fax:404-806-1779
Practice Address - Street 1:20 GLENLAKE PARKWAY
Practice Address - Street 2:KAISER PERMANENTE GLENLAKE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:404-686-7435
Practice Address - Fax:404-686-4473
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2010-11-19
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Provider Licenses
StateLicense IDTaxonomies
GARN082935363LF0000X
TX633458367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044374901Medicaid
TX044351705Medicaid
TX044374901Medicaid
TX8C9305Medicare ID - Type Unspecified607K
TX85N428Medicare ID - Type Unspecified606K
TX044351705Medicaid