Provider Demographics
NPI:1710085469
Name:HURST, LUSHUNDA M (PA)
Entity Type:Individual
Prefix:
First Name:LUSHUNDA
Middle Name:M
Last Name:HURST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-0371
Mailing Address - Country:US
Mailing Address - Phone:478-864-3448
Mailing Address - Fax:478-864-2244
Practice Address - Street 1:1008 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:GA
Practice Address - Zip Code:30828-9109
Practice Address - Country:US
Practice Address - Phone:706-465-3253
Practice Address - Fax:478-864-2244
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4402OtherLICENSE
GAMH3349594OtherDEA