MEDICARE: RAYMOND ROOT FNP-C

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	363LF0000X	Family Nurse Practitioner	APRN-NP277768	GA

General Provider Information

NPI Number	:	1366290843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND ROOT FNP-C

Provider Business Mailing Address
First Line	:	5791 ZEBULON RD STE A
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31210-2397
Country	:	US
Telephone Number	:	478-787-0410
Fax Number	:

Provider Business Practice Location Address
First Line	:	5791 ZEBULON RD STE A
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31210-2397
Country	:	US
Telephone Number	:	478-787-0410
Fax Number	:

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

Provider Enumeration Date	:	05/09/2024
Last Update Date	:	03/27/2026

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