Basic Information
| Provider Information | |||||||||
| NPI: | 1265558118 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGIA SOUTHERN UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GEORGIA SOUTHERN UNIVERSITY HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5199 | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796085199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668906390 | ||||||||
| FaxNumber: | 3254378390 | ||||||||
| Practice Location | |||||||||
| Address1: | 984 PLANT DRIVE | ||||||||
| Address2: | |||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124785641 | ||||||||
| FaxNumber: | 9124781893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NORRIS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTH SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9124785641 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA SOUTHERN UNIVERSITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.