Basic Information
| Provider Information | |||||||||
| NPI: | 1134175680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNIECE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 WESTOVER DR SW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301653453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062959342 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 REDMOND RD NW | ||||||||
| Address2: | ANESTHESIOLOGY DEPARTMENT | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062910291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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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 | 367H00000X | 001706 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100001196C | 05 | GA | MEDICAID | 100001196B | 05 | GA | MEDICAID | P00211519 | 01 | GA | RAILROAD MEDICARE | OTHER |