MEDICARE: SUJA P ANTONY NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	186261	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GRP4537	OTHER	GA	MEDICARE

General Provider Information

NPI Number	:	1255819447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUJA P ANTONY NP

Provider Business Mailing Address
First Line	:	4000 SAINT MARYS RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-7626
Country	:	US
Telephone Number	:	706-685-2770
Fax Number	:	706-685-3299

Provider Business Practice Location Address
First Line	:	4000 SAINT MARYS RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-7626
Country	:	US
Telephone Number	:	706-685-2770
Fax Number	:	706-685-3299

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2018
Last Update Date	:	07/31/2018

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