Provider Demographics
NPI:1831785906
Name:RAGAUSKAS, ALYSE MARY ELAINE
Entity type:Individual
Prefix:
First Name:ALYSE
Middle Name:MARY ELAINE
Last Name:RAGAUSKAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2102
Mailing Address - Country:US
Mailing Address - Phone:478-633-1851
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK STREET
Practice Address - Street 2:MSC#140
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-633-1851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13450208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program