Basic Information
Provider Information | |||||||||
NPI: | 1871686493 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OSWALD | ||||||||
FirstName: | BRENDA | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1499 WALTON WAY | ||||||||
Address2: | STE 1400 | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309012650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068286410 | ||||||||
FaxNumber: | 7067225187 | ||||||||
Practice Location | |||||||||
Address1: | 1120 15TH STREET | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067214951 | ||||||||
FaxNumber: | 7067217941 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
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 | 363AM0700X | 002605 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 100001266B | 05 | GA |   | MEDICAID | 0131PA | 05 | SC |   | MEDICAID |