MEDICARE: JESSICA WEGMANN CSFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	149391	GA
2	363AS0400X	Surgical Physician Assistant		GA

General Provider Information

NPI Number	:	1093128621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA WEGMANN CSFA

Provider Business Mailing Address
First Line	:	PO BOX 16957
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31416-3657
Country	:	US
Telephone Number	:	912-303-6678
Fax Number	:	912-355-3066

Provider Business Practice Location Address
First Line	:	5205 FREDERICK ST STE A
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31405-4520
Country	:	US
Telephone Number	:	912-303-6678
Fax Number	:	912-355-3066

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2014
Last Update Date	:	03/09/2015

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