Healthcare Provider Details

I. General information

NPI: 1164143558
Provider Name (Legal Business Name): ALISA BETH FERGUSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 HAWTHORNE PARK
ATHENS GA
30606-2148
US

IV. Provider business mailing address

3320 OLD JEFFERSON RD BLDG 700
ATHENS GA
30607-1465
US

V. Phone/Fax

Practice location:
  • Phone: 706-548-0500
  • Fax: 706-548-3575
Mailing address:
  • Phone: 706-353-2990
  • Fax: 706-353-2992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: