Provider Demographics
NPI:1619051455
Name:SHORT, DENNIS JAMES JR (PA)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:JAMES
Last Name:SHORT
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1525
Mailing Address - Country:US
Mailing Address - Phone:706-596-1245
Mailing Address - Fax:706-576-4245
Practice Address - Street 1:1942 NORTH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1525
Practice Address - Country:US
Practice Address - Phone:706-596-1245
Practice Address - Fax:706-576-4245
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1463363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical