Provider Demographics
NPI:1467454314
Name:POLK, RAYMOND EUGENE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:EUGENE
Last Name:POLK
Suffix:
Gender:M
Credentials:PA-C
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:134 ANSLEY DR STE 400
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1642
Practice Address - Country:US
Practice Address - Phone:706-864-1580
Practice Address - Fax:770-219-9561
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002539363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000066AMedicaid
GA100000066AMedicaid