Provider Demographics
NPI:1013528728
Name:HART, AUDRA
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 E 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-4010
Mailing Address - Country:US
Mailing Address - Phone:501-305-9857
Mailing Address - Fax:
Practice Address - Street 1:1111 GLYNCO PKWY STE 10
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7930
Practice Address - Country:US
Practice Address - Phone:912-264-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA11776363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program