Healthcare Provider Details

I. General information

NPI: 1366290843
Provider Name (Legal Business Name): RAYMOND ROOT FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5791 ZEBULON RD STE A
MACON GA
31210-2397
US

IV. Provider business mailing address

5791 ZEBULON RD STE A
MACON GA
31210-2397
US

V. Phone/Fax

Practice location:
  • Phone: 478-787-0410
  • Fax:
Mailing address:
  • Phone: 478-787-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP277768
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: