Provider Demographics
NPI:1578206082
Name:ROSHANRAVAN, ELHAM (NP)
Entity Type:Individual
Prefix:
First Name:ELHAM
Middle Name:
Last Name:ROSHANRAVAN
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 1:2721 BUFORD HWY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3507
Mailing Address - Country:US
Mailing Address - Phone:770-945-4800
Mailing Address - Fax:
Practice Address - Street 1:5755 N POINT PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1142
Practice Address - Country:US
Practice Address - Phone:678-240-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN293263363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily