Basic Information
| Provider Information | |||||||||
| NPI: | 1275635393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOWARD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WADE | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | AA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 804 SCOTT NIXON MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309072464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066500705 | ||||||||
| FaxNumber: | 7066501034 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MALL BLVD | ||||||||
| Address2: | SUITE T | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123557214 | ||||||||
| FaxNumber: | 5177877365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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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 | 367H00000X | 004890 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.