Healthcare Provider Details

I. General information

NPI: 1598775629
Provider Name (Legal Business Name): VANESA LAYNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

237 SASSAFRAS LANE
GROVETOWN GA
30813-7300
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax: 706-823-3983
Mailing address:
  • Phone: 706-364-1534
  • Fax: 706-823-3983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003706
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: