Provider Demographics
NPI:1295061208
Name:DOUGLAS, CAROLINE LOTT (PA-C)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:LOTT
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:NANCY
Other - Last Name:LOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:912-384-1470
Practice Address - Street 1:205 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2327
Practice Address - Country:US
Practice Address - Phone:912-260-5400
Practice Address - Fax:912-260-5177
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105371363AS0400X
GA005678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005678OtherMEDICAL LICENSE
GA858523224FMedicaid