Healthcare Provider Details

I. General information

NPI: 1922131382
Provider Name (Legal Business Name): SHANE LINDSAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1499 WALTON WAY SUITE 1400
AUGUSTA GA
30901-2602
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4951
  • Fax: 706-869-7380
Mailing address:
  • Phone: 706-724-6100
  • Fax: 706-724-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006635
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: