Provider Demographics
NPI:1518923218
Name:FORSTON, SHERRELL MONIQUE (PA C)
Entity Type:Individual
Prefix:
First Name:SHERRELL
Middle Name:MONIQUE
Last Name:FORSTON
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:SHERRELL
Other - Middle Name:MONIQUE
Other - Last Name:WINSTEAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:165 N PARK TRL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6500
Mailing Address - Country:US
Mailing Address - Phone:770-506-1800
Mailing Address - Fax:770-389-5947
Practice Address - Street 1:165 N PARK TRL
Practice Address - Street 2:SUITE 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6500
Practice Address - Country:US
Practice Address - Phone:770-506-1800
Practice Address - Fax:770-389-5947
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050766363A00000X
DEC5-0000616363A00000X
GA6338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA074795JTQMedicare ID - Type Unspecified
Q01517Medicare UPIN