Healthcare Provider Details

I. General information

NPI: 1417187204
Provider Name (Legal Business Name): DURGA AMAN SHAH PT, DPT, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1866 WILDWOOD PL NE
ATLANTA GA
30324-4908
US

IV. Provider business mailing address

1866 WILDWOOD PL NE
ATLANTA GA
30324-4908
US

V. Phone/Fax

Practice location:
  • Phone: 404-805-2629
  • Fax:
Mailing address:
  • Phone: 404-805-2629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7032
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number7032
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: