Healthcare Provider Details

I. General information

NPI: 1083109102
Provider Name (Legal Business Name): REBECCA LYNN PUETZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2018
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 SAINT SEBASTIAN WAY STE 311
AUGUSTA GA
30901-2653
US

IV. Provider business mailing address

1120 15TH ST # OR6000
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-3473
  • Fax:
Mailing address:
  • Phone: 706-721-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-006251
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9231
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: