Healthcare Provider Details

I. General information

NPI: 1770404733
Provider Name (Legal Business Name): AVERY THOMSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 COLISEUM DR STE 200
MACON GA
31217-3861
US

IV. Provider business mailing address

207 TRELLIS WALK
CENTERVILLE GA
31028-8511
US

V. Phone/Fax

Practice location:
  • Phone: 478-742-2180
  • Fax:
Mailing address:
  • Phone: 478-508-7458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14162
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: