Provider Demographics
NPI:1619305208
Name:LANDRY, ERIN (PAC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 SHANNON PKWY
Mailing Address - Street 2:STE D
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-1538
Mailing Address - Country:US
Mailing Address - Phone:770-964-1400
Mailing Address - Fax:770-306-1343
Practice Address - Street 1:176 CHARLES HARDY PKWY UNIT C
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-1836
Practice Address - Country:US
Practice Address - Phone:678-945-8200
Practice Address - Fax:678-945-8209
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7022363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7022OtherGEORGIA LICENSE