Healthcare Provider Details

I. General information

NPI: 1679882625
Provider Name (Legal Business Name): CLAY BRYAN CUSHMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 WALTON WAY STE 101
AUGUSTA GA
30904-4163
US

IV. Provider business mailing address

801 MONTE SANO AVE APT B1
AUGUSTA GA
30904-6172
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-1590
  • Fax:
Mailing address:
  • Phone: 706-825-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6011
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: