Provider Demographics
NPI:1487826269
Name:BHAKTA, MAYURI ASHOK (NP)
Entity Type:Individual
Prefix:
First Name:MAYURI
Middle Name:ASHOK
Last Name:BHAKTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 STAMP MILL CT
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-2406
Mailing Address - Country:US
Mailing Address - Phone:770-826-0332
Mailing Address - Fax:
Practice Address - Street 1:11460 JOHNS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1518
Practice Address - Country:US
Practice Address - Phone:678-415-2406
Practice Address - Fax:678-415-3120
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN168372363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily