Provider Demographics
NPI:1275087462
Name:WAUGH, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:WAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2095 HIGHWAY 211 NW # 147-2F
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-3402
Mailing Address - Country:US
Mailing Address - Phone:678-789-3057
Mailing Address - Fax:
Practice Address - Street 1:2095 HIGHWAY 211 NW # 147-2F
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3402
Practice Address - Country:US
Practice Address - Phone:678-789-3057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000000OtherCIGNA. BLUE CROSS, BLUE SHIELD, AETNA