Healthcare Provider Details

I. General information

NPI: 1508174343
Provider Name (Legal Business Name): ELISE M HULSEBUS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH STREET DEPARTMENT OF SURGERY
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST STE BI1056
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-8623
  • Fax: 706-721-1459
Mailing address:
  • Phone: 706-721-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1755
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005910
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: