Provider Demographics
NPI:1619032349
Name:PUTNAM, HELEN MINNETTA (OTRL, PA)
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:MINNETTA
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:OTRL, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E. HOSPITAL ROAD
Mailing Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-2535
Mailing Address - Fax:706-787-1327
Practice Address - Street 1:300 E. HOSPITAL ROAD
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-2535
Practice Address - Fax:706-787-1327
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001332225X00000X
GA005162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000692601BMedicaid