Provider Demographics
NPI:1275643710
Name:FYNE, LATANYA P (DPM)
Entity Type:Individual
Prefix:DR
First Name:LATANYA
Middle Name:P
Last Name:FYNE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 CENTRAL AVE.
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5850
Mailing Address - Country:US
Mailing Address - Phone:706-373-4402
Mailing Address - Fax:706-364-8628
Practice Address - Street 1:1710 CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5850
Practice Address - Country:US
Practice Address - Phone:706-373-4402
Practice Address - Fax:706-364-8628
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000619213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPD619Medicaid
SCGPD619Medicaid
GA5236900001Medicare NSC