=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255970422
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOBBI WEBB PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2020
-----------------------------------------------------
Last Update Date | 02/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3350 EBENEZER RD SE
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30094-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-209-2553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3160 MARY TODD LN
-----------------------------------------------------
City | DACULA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30019-1073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-565-2405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10230
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------