Provider Demographics
NPI:1689097099
Name:HARDISTY, JOHN (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HARDISTY
Suffix:
Gender:M
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 ROSS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35213-2547
Mailing Address - Country:US
Mailing Address - Phone:205-705-9178
Mailing Address - Fax:
Practice Address - Street 1:1201 7TH ST SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3337
Practice Address - Country:US
Practice Address - Phone:256-341-3328
Practice Address - Fax:256-341-2605
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALTA.1771363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical