Provider Demographics
NPI:1306972781
Name:HEDRICK, JAMES (PAC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:HEDRICK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6925
Mailing Address - Country:US
Mailing Address - Phone:229-985-3420
Mailing Address - Fax:
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-985-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002266AMedicaid
GAP63504Medicare UPIN
GA97WCDCKMedicare PIN
GA511I970598Medicare PIN