Provider Demographics
NPI:1811087299
Name:NIX, JONATHAN LEE (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LEE
Last Name:NIX
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 OGLETHORPE AVE
Mailing Address - Street 2:SUITE 300A
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2179
Mailing Address - Country:US
Mailing Address - Phone:706-543-5858
Mailing Address - Fax:706-543-2050
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 300A
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-543-5858
Practice Address - Fax:706-543-2050
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA003568363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP28140Medicare UPIN