Basic Information
| Provider Information | |||||||||
| NPI: | 1811537574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | LANCE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W 3RD AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293125800 | ||||||||
| FaxNumber: | 2293125815 | ||||||||
| Practice Location | |||||||||
| Address1: | 1390 US HIGHWAY 19 S | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317634831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298897490 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2020 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN219164 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.