Provider Demographics
NPI:1245376573
Name:MIXON, DIANNE S (PA-C)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:S
Last Name:MIXON
Suffix:
Gender:F
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 1:1608 MEADOWS LN STE 1
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-9907
Mailing Address - Country:US
Mailing Address - Phone:912-537-9488
Mailing Address - Fax:912-537-8951
Practice Address - Street 1:1608 MEADOWS LN STE 1
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-9907
Practice Address - Country:US
Practice Address - Phone:912-537-9488
Practice Address - Fax:912-537-8951
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001382AMedicaid
GAN34071Medicare UPIN
GA100001382AMedicaid