Provider Demographics
NPI:1942411038
Name:VAILLANT, GEORGE ROGER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:ROGER
Last Name:VAILLANT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 STEELE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4597
Mailing Address - Country:US
Mailing Address - Phone:706-544-9426
Mailing Address - Fax:
Practice Address - Street 1:119 STEELE CREEK DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:GA
Practice Address - Zip Code:31820-4597
Practice Address - Country:US
Practice Address - Phone:706-544-9426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002272363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical