Provider Demographics
NPI:1912673245
Name:POAG, SHAVON
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:POAG
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 1:1920 OLD DOGWOOD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-7514
Mailing Address - Country:US
Mailing Address - Phone:470-364-7186
Mailing Address - Fax:
Practice Address - Street 1:122 N MCDONOUGH ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3023
Practice Address - Country:US
Practice Address - Phone:470-364-7186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management