Provider Demographics
NPI:1013965961
Name:SHONGO, AVRIL PATRICE DAISLEY (MD)
Entity Type:Individual
Prefix:
First Name:AVRIL PATRICE
Middle Name:DAISLEY
Last Name:SHONGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:SUITE A#519
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4639
Mailing Address - Country:US
Mailing Address - Phone:678-783-4860
Mailing Address - Fax:678-935-7210
Practice Address - Street 1:3312 HEATHCHASE LN
Practice Address - Street 2:ADDRESS LINE 2
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4639
Practice Address - Country:US
Practice Address - Phone:678-783-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA43028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003210796AMedicaid
G59313Medicare UPIN