Provider Demographics
NPI:1710728431
Name:HARDISON, ALLY LYNNE (PA)
Entity type:Individual
Prefix:
First Name:ALLY
Middle Name:LYNNE
Last Name:HARDISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 BULL ST UNIT 5&6
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-7255
Mailing Address - Country:US
Mailing Address - Phone:912-200-6490
Mailing Address - Fax:
Practice Address - Street 1:1512 BULL ST UNIT 5&6
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-7255
Practice Address - Country:US
Practice Address - Phone:912-200-6490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty