Provider Demographics
NPI:1649596867
Name:WOMBLE, GEORGIA ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:ANN
Last Name:WOMBLE
Suffix:
Gender:F
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:18780 INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-3593
Practice Address - Country:US
Practice Address - Phone:903-567-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06694363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-001OtherTRICARE
TX351539702Medicaid
TX8334NZOtherBCBS
TXP01787495OtherRAIL ROAD MEDICARE
TXP01787495OtherRAIL ROAD MEDICARE
TX351539702Medicaid