Healthcare Provider Details

I. General information

NPI: 1609048024
Provider Name (Legal Business Name): TIA ALYNN GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 ALICE ST
WAYCROSS GA
31501-4525
US

IV. Provider business mailing address

PO BOX 294 501 OLD PEARSON RD
HOMERVILLE GA
31634-0294
US

V. Phone/Fax

Practice location:
  • Phone: 912-284-9800
  • Fax:
Mailing address:
  • Phone: 229-630-4073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: