{
"Npi": {
"NPI": "1538319249",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "CAVAZOS",
"FirstName": "SHANDAREDA",
"MiddleName": "CHANTAY",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "PA-C, MMSC",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "SEWELL",
"OtherFirstName": "SHANDAREDA",
"OtherMiddleName": "CHANTAY",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": "PAC",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "1100 JOHNSON FERRY RD STE 410",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ATLANTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30342-1709",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "404-847-0664",
"MailingAddressFaxNumber": "404-250-1694",
"FirstLinePracticeLocationAddress": "1100 JOHNSON FERRY RD STE 410",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "ATLANTA",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30342-1709",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "404-847-0664",
"PracticeLocationAddressFaxNumber": "404-250-1694",
"EnumerationDate": "09/30/2008",
"LastUpdateDate": "08/26/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "004742",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}