Provider Demographics
NPI:1417074147
Name:GANTT, ASHLEY S (PA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:S
Last Name:GANTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:SYREECE
Other - Last Name:WADDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3820 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1110
Mailing Address - Country:US
Mailing Address - Phone:770-948-6041
Mailing Address - Fax:770-739-5411
Practice Address - Street 1:3820 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-948-6041
Practice Address - Fax:770-819-2987
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant