1710085469 NPI number — LUSHUNDA M HURST P.A.

Table of content: LUSHUNDA M HURST P.A. (NPI 1710085469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710085469 NPI number — LUSHUNDA M HURST P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HURST
Provider First Name:
LUSHUNDA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710085469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 371
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WRIGHTSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31096-0371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-864-3448
Provider Business Mailing Address Fax Number:
478-864-2244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 ATLANTA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARRENTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30828-9109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-465-3253
Provider Business Practice Location Address Fax Number:
478-864-2244
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  4402 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4402 . This is a "LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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