Provider Demographics
NPI:1366523292
Name:DIAL, JONATHAN S (PA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:S
Last Name:DIAL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 TEBEAU ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-6357
Mailing Address - Country:US
Mailing Address - Phone:912-338-6368
Mailing Address - Fax:912-338-7113
Practice Address - Street 1:1900 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6357
Practice Address - Country:US
Practice Address - Phone:912-338-6368
Practice Address - Fax:912-338-7113
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004822363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical