Provider Demographics
NPI:1679855001
Name:LAVIGNO, SHIMA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHIMA
Middle Name:
Last Name:LAVIGNO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHIMA
Other - Middle Name:
Other - Last Name:MANSOURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3890 JOHNS CREEK PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1285
Mailing Address - Country:US
Mailing Address - Phone:678-472-9985
Mailing Address - Fax:
Practice Address - Street 1:3890 JOHNS CREEK PKWY STE 120
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1285
Practice Address - Country:US
Practice Address - Phone:678-472-9985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6185363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical