Basic Information
| Provider Information | |||||||||
| NPI: | 1811993041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEST | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WEST | ||||||||
| OtherFirstName: | JAN | ||||||||
| OtherMiddleName: | L. | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301068116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709442830 | ||||||||
| FaxNumber: | 6785817170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 J L WHITE DR | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301434908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066920603 | ||||||||
| FaxNumber: | 6785817109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 003557 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1811993041 | 01 | GA | NPI | OTHER |