Provider Demographics
NPI:1437163979
Name:JIMENEZ, ROBYN E (PAC)
Entity Type:Individual
Prefix:MS
First Name:ROBYN
Middle Name:E
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PAC
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:229-263-4671
Practice Address - Street 1:905 N COURT ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643
Practice Address - Country:US
Practice Address - Phone:229-263-8956
Practice Address - Fax:229-263-4671
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002868BMedicaid
GA100002868BMedicaid
P03721Medicare UPIN
GAGRP2501Medicare ID - Type UnspecifiedMCARE GROUP