Provider Demographics
NPI:1891815924
Name:ROWE, JOHN DAVID JR (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:ROWE
Suffix:JR
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N IRWIN AVE
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-5011
Mailing Address - Country:US
Mailing Address - Phone:229-468-3800
Mailing Address - Fax:229-468-9991
Practice Address - Street 1:134 FLEETWOOD AVE E
Practice Address - Street 2:
Practice Address - City:WILLACOOCHEE
Practice Address - State:GA
Practice Address - Zip Code:31650-2730
Practice Address - Country:US
Practice Address - Phone:912-534-5142
Practice Address - Fax:912-534-6120
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002799FMedicaid
GA20297I2956Medicare PIN
GA97WCJQZMedicare PIN