Healthcare Provider Details

I. General information

NPI: 1164560470
Provider Name (Legal Business Name): LAUREN POWELL MUSGROVE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN B. POWELL PA-C

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 GORDON AVE
THOMASVILLE GA
31792-6645
US

IV. Provider business mailing address

3334 CAPITAL MEDICAL BLVD STE 400
TALLAHASSEE FL
32308-4470
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-3060
  • Fax: 855-460-8658
Mailing address:
  • Phone: 850-877-8174
  • Fax: 844-261-6839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004879
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: