Healthcare Provider Details

I. General information

NPI: 1952979619
Provider Name (Legal Business Name): JASON TOWNLEY LITTLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/26/2021
Certification Date: 06/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MIMOSA DR
THOMASVILLE GA
31792-6676
US

IV. Provider business mailing address

5213 HICKORY GROVE CIR
PINSON AL
35126-4400
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-8881
  • Fax:
Mailing address:
  • Phone: 205-478-0498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1768
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: