Healthcare Provider Details

I. General information

NPI: 1447955398
Provider Name (Legal Business Name): MAX RICARDO ESTRADA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 CLIFTON RD NE
ATLANTA GA
30322-4200
US

IV. Provider business mailing address

453 GREG DR SW
LILBURN GA
30047-5207
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7551
  • Fax:
Mailing address:
  • Phone: 678-571-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN225205
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: