Basic Information
| Provider Information | |||||||||
| NPI: | 1073769832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEWBY | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3857 HAMLIN FLOYD RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310448019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786971107 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3051 WATSON BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789537556 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 08/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT001497 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.