Provider Demographics
NPI:1992757314
Name:BUNT, JANICE LEE (PA)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:LEE
Last Name:BUNT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-7311
Mailing Address - Country:US
Mailing Address - Phone:706-596-1750
Mailing Address - Fax:
Practice Address - Street 1:616 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-494-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004144367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q00226Medicare UPIN
GA32BBBMQMedicare PIN