Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | 016295 | GA |
N | 207RR0500X | Rheumatology | 40533 | SC |
NPI | 1104804863 |
---|---|
Provider Name | Johnathan Paul Vansant |
First Address | Blairsville, GA 30512-3139 |
Second Address | Blairsville, GA 30512-3139 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2006 |
Last Update Date | 07/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000135382I | (05) | GA |
D31087 | (02) | GA |
PENDING | (05) | SC |