Provider Demographics
NPI:1548569502
Name:WANDURRAGA, MEGAN M (NP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:WANDURRAGA
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 1:2750 OWENS DR
Mailing Address - Street 2:STE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094
Mailing Address - Country:US
Mailing Address - Phone:678-413-4644
Mailing Address - Fax:678-413-4624
Practice Address - Street 1:2750 OWENS RD SW
Practice Address - Street 2:STE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3991
Practice Address - Country:US
Practice Address - Phone:678-413-4644
Practice Address - Fax:678-413-4624
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN203584363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner