Provider Demographics
NPI:1831476506
Name:DE LA MOTTE HURST, NICHOLAS Q (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:Q
Last Name:DE LA MOTTE HURST
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3237 SATELLITE BLVD STE 425
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-9009
Mailing Address - Country:US
Mailing Address - Phone:678-257-2547
Mailing Address - Fax:404-795-5832
Practice Address - Street 1:1498 JESSE JEWELL PKWY SE STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3874
Practice Address - Country:US
Practice Address - Phone:678-257-2547
Practice Address - Fax:404-795-5832
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53067363AS0400X
GA390200000X
GA006327363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53067Medicare UPIN
CAW268Medicare UPIN
GA202I972028Medicare PIN
GA003119788IMedicaid