Provider Demographics
NPI:1902465719
Name:HEARD, ELIZABETH LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LAURA
Last Name:HEARD
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 1:900 CIRCLE 75 PKWY SE STE 1700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3087
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:
Practice Address - Street 1:3672 MARATHON CIR STE 200
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6821
Practice Address - Country:US
Practice Address - Phone:770-944-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant