Basic Information
| Provider Information | |||||||||
| NPI: | 1871692897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANERAL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 529 | ||||||||
| Address2: | |||||||||
| City: | ROYSTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306620529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066217575 | ||||||||
| FaxNumber: | 7066217557 | ||||||||
| Practice Location | |||||||||
| Address1: | 961 E WINTHROPE AVE | ||||||||
| Address2: | |||||||||
| City: | MILLEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304421839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062942196 | ||||||||
| FaxNumber: | 6788190357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 08/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 004211 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 449873228E | 05 | GA | MEDICAID | 449873228H | 05 | GA | MEDICAID | 449873228D | 05 | GA | MEDICAID | 449873228F | 05 | GA | MEDICAID | 449873228C | 05 | GA | MEDICAID | 449873228G | 05 | GA | MEDICAID |