Provider Demographics
NPI:1992187033
Name:HURTADO, SANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:HURTADO
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 1:5788 ROSWELL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4904
Mailing Address - Country:US
Mailing Address - Phone:404-935-9110
Mailing Address - Fax:770-234-6803
Practice Address - Street 1:5788 ROSWELL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4904
Practice Address - Country:US
Practice Address - Phone:404-935-9110
Practice Address - Fax:770-234-6803
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7446363A00000X
SC2501363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant