Healthcare Provider Details

I. General information

NPI: 1811087299
Provider Name (Legal Business Name): JONATHAN LEE NIX PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 OGLETHORPE AVE SUITE 300A
ATHENS GA
30606-2179
US

IV. Provider business mailing address

1500 OGLETHORPE AVE SUITE 300A
ATHENS GA
30606-2179
US

V. Phone/Fax

Practice location:
  • Phone: 706-543-5858
  • Fax: 706-543-2050
Mailing address:
  • Phone: 706-543-5858
  • Fax: 706-543-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003568
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003568
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: