Provider Demographics
NPI:1033990601
Name:PANTA, SRUTTE
Entity Type:Individual
Prefix:
First Name:SRUTTE
Middle Name:
Last Name:PANTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 ROYAL CREEK WAY SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1884
Mailing Address - Country:US
Mailing Address - Phone:404-345-4420
Mailing Address - Fax:
Practice Address - Street 1:3151 ROYAL CREEK WAY SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1884
Practice Address - Country:US
Practice Address - Phone:404-345-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN267277363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty