Provider Demographics
NPI:1972977684
Name:HARDY, ANGELA J (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:HARDY
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 1:10 NORTH 3RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MC RAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055
Mailing Address - Country:US
Mailing Address - Phone:229-868-2831
Mailing Address - Fax:
Practice Address - Street 1:10 NORTH 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055
Practice Address - Country:US
Practice Address - Phone:229-868-2831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2414363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2414OtherPA LICENSE