Provider Demographics
NPI:1205465895
Name:HEARD, GILLIAN VAUGHAN (PA-C)
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:VAUGHAN
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 1:12484 WOODBURY HWY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30222
Mailing Address - Country:US
Mailing Address - Phone:770-823-3879
Mailing Address - Fax:
Practice Address - Street 1:1275 GA-54 #201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9715363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty