Healthcare Provider Details

I. General information

NPI: 1982093902
Provider Name (Legal Business Name): JAMIE MATHIS GANN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DONNA JEAN MATHIS

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 DOWDY RD SUITE 100
ATHENS GA
30606-5700
US

IV. Provider business mailing address

PO BOX 529
ROYSTON GA
30662-0529
US

V. Phone/Fax

Practice location:
  • Phone: 706-621-7575
  • Fax: 706-621-7557
Mailing address:
  • Phone: 706-621-7561
  • Fax: 706-621-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7459
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: