Provider Demographics
NPI:1508301649
Name:KHERA, MA VICTORIA AQUINO (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MA VICTORIA
Middle Name:AQUINO
Last Name:KHERA
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:MA VICTORIA
Other - Middle Name:VILLANUEVA
Other - Last Name:AQUINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:608 BURGAMY PASS
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5855
Mailing Address - Country:US
Mailing Address - Phone:714-624-5631
Mailing Address - Fax:
Practice Address - Street 1:2467 GOLDEN CAMP RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-5515
Practice Address - Country:US
Practice Address - Phone:706-790-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA243278363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care