Provider Demographics
NPI:1447312400
Name:CLEMMONS, JOSEPH WILLIAM (PA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:WILLIAM
Last Name:CLEMMONS
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 1:1538 13TH. AVE
Mailing Address - Street 2:SUITE B300
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3700
Mailing Address - Country:US
Mailing Address - Phone:706-321-9300
Mailing Address - Fax:706-321-9384
Practice Address - Street 1:1538 13TH. AVE
Practice Address - Street 2:SUITE B300
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3700
Practice Address - Country:US
Practice Address - Phone:706-321-9300
Practice Address - Fax:706-321-9384
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1538363AS0400X
GA001538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001103DMedicaid
GA97WCGNDMedicare ID - Type Unspecified