Provider Demographics
NPI:1407191836
Name:EHTESHAMI, LAURA CAPALBO (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:CAPALBO
Last Name:EHTESHAMI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:SUSAN
Other - Last Name:CAPALBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:105 COLLIER RD NW
Mailing Address - Street 2:SUITE 5020
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1710
Mailing Address - Country:US
Mailing Address - Phone:404-351-7467
Mailing Address - Fax:404-719-4113
Practice Address - Street 1:105 COLLIER RD NW
Practice Address - Street 2:SUITE 5020
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1710
Practice Address - Country:US
Practice Address - Phone:404-351-7467
Practice Address - Fax:404-719-4113
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant