Provider Demographics
NPI:1245207414
Name:FOSSETT, PHYLLIS R (CRNA)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:R
Last Name:FOSSETT
Suffix:
Gender:F
Credentials:CRNA
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 2564
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203
Mailing Address - Country:US
Mailing Address - Phone:478-746-5644
Mailing Address - Fax:478-745-4849
Practice Address - Street 1:380 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-746-5644
Practice Address - Fax:478-745-4849
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN066808367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000582788DMedicaid
GA000582788FMedicaid
GA000582788EMedicaid
GA430032146OtherRAILROAD MEDICARE
GA430060612OtherPALMETTO GBA
GA391026OtherWELLCARE
GA430060612OtherPALMETTO GBA
GA000582788DMedicaid
GA43ZCBDP16Medicare PIN