Provider Demographics
NPI:1780225664
Name:HUERTA, ABIGAIL (PA)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:HUERTA
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 1:301 PHILIP BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8746
Mailing Address - Country:US
Mailing Address - Phone:770-822-5560
Mailing Address - Fax:770-822-4989
Practice Address - Street 1:301 PHILIP BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8746
Practice Address - Country:US
Practice Address - Phone:770-822-5560
Practice Address - Fax:770-822-4989
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA00000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program