Provider Demographics
NPI:1710081989
Name:RAY, WALTER SHANNON (PAC)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:SHANNON
Last Name:RAY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DOCTORS DR
Mailing Address - Street 2:STE 103
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2210
Mailing Address - Country:US
Mailing Address - Phone:912-383-9789
Mailing Address - Fax:912-383-9435
Practice Address - Street 1:100 DOCTORS DR
Practice Address - Street 2:STE 103
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2210
Practice Address - Country:US
Practice Address - Phone:912-383-9789
Practice Address - Fax:912-383-9435
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002000AMedicaid
97BBHFHMedicare ID - Type Unspecified