Provider Demographics
NPI:1710068770
Name:OATES, SHIRLEY MIKE (CERTIFIED PEDIATRIC)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:MIKE
Last Name:OATES
Suffix:
Gender:F
Credentials:CERTIFIED PEDIATRIC
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 569
Mailing Address - Street 2:414 LUGENIA BLVD
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475
Mailing Address - Country:US
Mailing Address - Phone:912-537-9355
Mailing Address - Fax:912-537-7038
Practice Address - Street 1:414 LUGENIA BLVD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-9355
Practice Address - Fax:912-537-7038
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN115236363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00692392CMedicaid