Provider Demographics
NPI:1700065422
Name:RETBERG, DAVID A (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:RETBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:7316 SPOUT SPRINGS RD STE 203
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5620
Practice Address - Country:US
Practice Address - Phone:678-205-8387
Practice Address - Fax:678-808-1039
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0013363A00000X, 363AM0700X
GA9308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPA2009-0013OtherNM LICENSE