Healthcare Provider Details

I. General information

NPI: 1891815924
Provider Name (Legal Business Name): JOHN DAVID ROWE JR. PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 FLEETWOOD AVE E
WILLACOOCHEE GA
31650-2730
US

IV. Provider business mailing address

710 N IRWIN AVE
OCILLA GA
31774-5011
US

V. Phone/Fax

Practice location:
  • Phone: 912-534-5142
  • Fax: 912-534-6120
Mailing address:
  • Phone: 229-468-3800
  • Fax: 229-468-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003941
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: