Provider Demographics
NPI:1891957353
Name:WHISENANT, EBONY B (MD)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:B
Last Name:WHISENANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1120 15TH ST STE BI1056
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-3813
Mailing Address - Fax:
Practice Address - Street 1:AUGUSTA UNIVERSITY MEDICAL CTR 1120 15TH STREET
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-2516
Practice Address - Country:US
Practice Address - Phone:706-721-8623
Practice Address - Fax:706-721-1459
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME106882207Q00000X
FLTRN12292207Q00000X
GA83947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA83947OtherGEORGIA MEDICAL LICENSE