Provider Demographics
NPI:1134588270
Name:PRIDE, LAURA BORDEU (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:BORDEU
Last Name:PRIDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 STONEFOREST DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4881
Mailing Address - Country:US
Mailing Address - Phone:770-423-0595
Mailing Address - Fax:678-388-1627
Practice Address - Street 1:61 WHITCHER ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-423-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7889363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical