Provider Demographics
NPI:1093816662
Name:WINBUSH, SHONTA K (PA)
Entity Type:Individual
Prefix:MS
First Name:SHONTA
Middle Name:K
Last Name:WINBUSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643
Mailing Address - Country:US
Mailing Address - Phone:229-263-8956
Mailing Address - Fax:
Practice Address - Street 1:704 GIL HARBIN IND BLVD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-242-9003
Practice Address - Fax:229-242-0490
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA244832811AMedicaid
GRP2501Medicare ID - Type UnspecifiedMCARE GROUP NUMBER
GA97WCHGPMedicare ID - Type Unspecified
GA244832811AMedicaid