Healthcare Provider Details

I. General information

NPI: 1689002834
Provider Name (Legal Business Name): MAGGIE L. GEORGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2013
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 FRANKLIN RD SW
ROANOKE VA
24014-1111
US

IV. Provider business mailing address

2331 FRANKLIN RD SW
ROANOKE VA
24014-1111
US

V. Phone/Fax

Practice location:
  • Phone: 540-725-1226
  • Fax: 540-857-5306
Mailing address:
  • Phone: 540-510-6200
  • Fax: 540-857-5306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002083
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110005514
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: