Provider Demographics
NPI:1124611017
Name:HART, SHANDRA LUNETTE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANDRA
Middle Name:LUNETTE
Last Name:HART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1046 RIDGE AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1640
Mailing Address - Country:US
Mailing Address - Phone:404-688-1350
Mailing Address - Fax:470-593-7784
Practice Address - Street 1:116 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2527
Practice Address - Country:US
Practice Address - Phone:404-564-7042
Practice Address - Fax:404-241-6256
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA10236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant