Healthcare Provider Details

I. General information

NPI: 1992187033
Provider Name (Legal Business Name): SANDRA HURTADO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5788 ROSWELL RD SUITE 200
ATLANTA GA
30328-4904
US

IV. Provider business mailing address

5788 ROSWELL RD SUITE 200
ATLANTA GA
30328-4904
US

V. Phone/Fax

Practice location:
  • Phone: 404-935-9110
  • Fax: 770-234-6803
Mailing address:
  • Phone: 404-935-9110
  • Fax: 770-234-6803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7446
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: