Healthcare Provider Details

I. General information

NPI: 1124854294
Provider Name (Legal Business Name): GEORGINA ELISE BOARDLEY PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

353 WELLSTONE WAY
RICHMOND HILL GA
31324-7877
US

V. Phone/Fax

Practice location:
  • Phone: 407-288-5246
  • Fax:
Mailing address:
  • Phone: 407-288-5246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: