Basic Information
| Provider Information | |||||||||
| NPI: | 1043835317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAYSON | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1053 CHAFEE AVE | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309045855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295063248 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1459 LANEY WALKER BLVD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067212273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2020 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 11976 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 11976 | 01 | GA | GEORGIA COMPOSITE MEDICAL BOARD | OTHER |