Provider Demographics
NPI:1952957052
Name:GUPTA, SANDHYA (PA-C)
Entity type:Individual
Prefix:
First Name:SANDHYA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
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 1:755 WALTHER RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8725
Mailing Address - Country:US
Mailing Address - Phone:678-272-3699
Mailing Address - Fax:770-290-8084
Practice Address - Street 1:755 WALTHER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8725
Practice Address - Country:US
Practice Address - Phone:678-272-3699
Practice Address - Fax:770-290-8084
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9409207QA0505X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1160403OtherNCCPA
GA9409OtherGEORGIA MEDICAL COMPOSITE BOARD