Healthcare Provider Details

I. General information

NPI: 1245376573
Provider Name (Legal Business Name): DIANNE S MIXON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 MEADOWS LN STE 1
VIDALIA GA
30474-9907
US

IV. Provider business mailing address

1608 MEADOWS LN STE 1
VIDALIA GA
30474-9907
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-9488
  • Fax: 912-537-8951
Mailing address:
  • Phone: 912-537-9488
  • Fax: 912-537-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000330
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: