Basic Information
Provider Information | |||||||||
NPI: | 1790757714 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHADBURN | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 658 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305030658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707181122 | ||||||||
FaxNumber: | 7705348998 | ||||||||
Practice Location | |||||||||
Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305013834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705353611 | ||||||||
FaxNumber: | 7705357092 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2006 | ||||||||
LastUpdateDate: | 08/16/2011 | ||||||||
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 | 363LP0200X | RN051454 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 000733268E | 05 | GA |   | MEDICAID | 303687 | 01 | GA | WELLCARE | OTHER | 303688 | 01 | GA | WELLCARE | OTHER | 303689 | 01 | GA | WELLCARE | OTHER | 000733268F | 05 | GA |   | MEDICAID | 303674 | 01 | GA | WELLCARE | OTHER | 10032995 | 01 | GA | AMERIGROUP | OTHER | 000733268A | 05 | GA |   | MEDICAID | 000733268B | 05 | GA |   | MEDICAID |