Provider Demographics
NPI:1518933373
Name:HEARD, HENRY H (PA)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:H
Last Name:HEARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 ASBURY CIRCLE-ANNEX
Mailing Address - Street 2:SUITE N340
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-0001
Mailing Address - Country:US
Mailing Address - Phone:404-778-5975
Mailing Address - Fax:404-778-2630
Practice Address - Street 1:6325 W JOHNS XING
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-1530
Practice Address - Country:US
Practice Address - Phone:404-778-5975
Practice Address - Fax:404-778-2630
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001407363AM0700X
GA1407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA139935198Medicaid
GA139935198Medicaid
GAS61806Medicare UPIN