Provider Demographics
NPI:1417057977
Name:POE, JONELL B (PA)
Entity Type:Individual
Prefix:
First Name:JONELL
Middle Name:B
Last Name:POE
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 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2650
Mailing Address - Country:US
Mailing Address - Phone:706-828-6410
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH STREET
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-2198
Practice Address - Fax:706-721-5748
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3209363A00000X
GA003209363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0112PAMedicaid
GA100001728AMedicaid
GA97BBGBCMedicare ID - Type UnspecifiedGA MEDICARE
GA100001728AMedicaid