Provider Demographics
NPI:1972632701
Name:LUTFI, LADAN (PA-C)
Entity type:Individual
Prefix:
First Name:LADAN
Middle Name:
Last Name:LUTFI
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 1:5673 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:STE 350
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1731
Mailing Address - Country:US
Mailing Address - Phone:404-778-8065
Mailing Address - Fax:678-843-6693
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:STE350
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-778-8065
Practice Address - Fax:678-843-6693
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005004363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005004OtherGA LIC#