Provider Demographics
NPI:1760436752
Name:JEWETT, SAMUEL L III (PA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:JEWETT
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:715 KNIGHT BOTTOM RD SE
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:GA
Mailing Address - Zip Code:30139-2053
Mailing Address - Country:US
Mailing Address - Phone:770-608-9379
Mailing Address - Fax:770-773-3080
Practice Address - Street 1:6000 JOE FRANK HARRIS PKWY NW
Practice Address - Street 2:SUITE D
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2443
Practice Address - Country:US
Practice Address - Phone:770-773-9201
Practice Address - Fax:770-773-3080
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS90959Medicare UPIN
GA97WCDZPMedicare ID - Type Unspecified