Provider Demographics
NPI:1023310182
Name:CEYSSENS, WOUTER JOHAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:WOUTER
Middle Name:JOHAN
Last Name:CEYSSENS
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 1:3121 PEACH ORCHARD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-3521
Mailing Address - Country:US
Mailing Address - Phone:706-792-5040
Mailing Address - Fax:706-792-5045
Practice Address - Street 1:3121 PEACH ORCHARD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3521
Practice Address - Country:US
Practice Address - Phone:706-792-5040
Practice Address - Fax:706-792-5045
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1045790OtherNCCPA CERTIFICATION
GA358488587AMedicaid