Provider Demographics
NPI:1699540112
Name:MINGO, CALEB (CAA)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:MINGO
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ALLEN LN
Mailing Address - Street 2:
Mailing Address - City:NAHUNTA
Mailing Address - State:GA
Mailing Address - Zip Code:31553-2060
Mailing Address - Country:US
Mailing Address - Phone:912-285-4983
Mailing Address - Fax:
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:912-283-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11891367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant