Provider Demographics
NPI:1205678554
Name:BAGHERI, SHAYAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:SHAYAN
Middle Name:
Last Name:BAGHERI
Suffix:
Gender:M
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 1:204 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2304
Mailing Address - Country:US
Mailing Address - Phone:770-886-5437
Mailing Address - Fax:
Practice Address - Street 1:204 CANTON RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2304
Practice Address - Country:US
Practice Address - Phone:770-886-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-08
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical