Basic Information
Provider Information | |||||||||
NPI: | 1548264047 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUBOSE | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | ELAINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DUBOSE | ||||||||
OtherFirstName: | SANDRA | ||||||||
OtherMiddleName: | JONES | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 FREEDOM WAY | ||||||||
Address2: | ROUTER 21 | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309046258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067330188 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 FREEDOM WAY | ||||||||
Address2: | ROUTER 313 | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309046258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067330188 | ||||||||
FaxNumber: | 7064816729 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2005 | ||||||||
LastUpdateDate: | 10/26/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN103532 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 129 | SC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 000829595A | 05 | GA |   | MEDICAID | NP0278 | 05 | SC |   | MEDICAID |