Healthcare Provider Details

I. General information

NPI: 1619493517
Provider Name (Legal Business Name): CODY ROBERT WARD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 FAIR RD
STATESBORO GA
30458-1683
US

IV. Provider business mailing address

5629 HWY 21 S
RINCON GA
31326-9416
US

V. Phone/Fax

Practice location:
  • Phone: 912-486-1510
  • Fax:
Mailing address:
  • Phone: 912-295-2133
  • Fax: 912-295-5924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: