Provider Demographics
NPI:1366290843
Name:ROOT, RAYMOND (FNP-C)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:ROOT
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2247
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-2247
Mailing Address - Country:US
Mailing Address - Phone:478-654-5327
Mailing Address - Fax:
Practice Address - Street 1:110 JAILHOUSE ALY
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-3200
Practice Address - Country:US
Practice Address - Phone:478-654-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN277768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily