Provider Demographics
NPI:1104348432
Name:SURRENCY, GARRETT SHANE (ADVANCED CARE NP)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:SHANE
Last Name:SURRENCY
Suffix:
Gender:M
Credentials:ADVANCED CARE NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 654
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:GA
Mailing Address - Zip Code:31647-0654
Mailing Address - Country:US
Mailing Address - Phone:229-848-9383
Mailing Address - Fax:
Practice Address - Street 1:2225 US HIGHWAY 41 N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2749
Practice Address - Country:US
Practice Address - Phone:229-391-4270
Practice Address - Fax:229-391-4250
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA162472363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care