Basic Information
| Provider Information | |||||||||
| NPI: | 1336108141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LINEHAN-BURACK | ||||||||
| FirstName: | JEANINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3726 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309143726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639595 | ||||||||
| FaxNumber: | 7068688375 | ||||||||
| Practice Location | |||||||||
| Address1: | 3675 J DEWEY GRAY CIR STE 300 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309091868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639595 | ||||||||
| FaxNumber: | 7068688375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA9111128 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA-1741 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA13075 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 0110007257 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA0000004410 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 0010-10111 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA1200 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 004463 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 519646861A | 05 | GA | MEDICAID | 0282PA | 05 | SC | MEDICAID |