Provider Demographics
NPI:1710528401
Name:BOOMGARDEN, HANNAH INGRID (PA-C)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:INGRID
Last Name:BOOMGARDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 RENAULT LN NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3442
Mailing Address - Country:US
Mailing Address - Phone:770-316-0494
Mailing Address - Fax:
Practice Address - Street 1:1467 HARPER STREET HB 5040
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-5775
Practice Address - Country:US
Practice Address - Phone:706-721-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9506363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical