Provider Demographics
NPI:1013026962
Name:FONDRK, JOLENE STEWART (PA-C)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:STEWART
Last Name:FONDRK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JOLENE
Other - Middle Name:MARIE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:6262 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3540
Practice Address - Country:US
Practice Address - Phone:706-324-6661
Practice Address - Fax:706-327-6701
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558282Medicare PIN
GA97WCJBJMedicare PIN
Q72661Medicare UPIN