Healthcare Provider Details

I. General information

NPI: 1669814034
Provider Name (Legal Business Name): GWENDOLYN LEIGHANN SHEARER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 UPPER HEMBREE RD
ROSWELL GA
30076-0927
US

IV. Provider business mailing address

1505 NORTHSIDE BLVD STE 2000
CUMMING GA
30041-6205
US

V. Phone/Fax

Practice location:
  • Phone: 770-569-0777
  • Fax: 770-569-7631
Mailing address:
  • Phone: 770-781-4010
  • Fax: 770-781-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2510
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: