Provider Demographics
NPI:1538319249
Name:CAVAZOS, SHANDAREDA CHANTAY (PA-C, MMSC)
Entity type:Individual
Prefix:
First Name:SHANDAREDA
Middle Name:CHANTAY
Last Name:CAVAZOS
Suffix:
Gender:F
Credentials:PA-C, MMSC
Other - Prefix:
Other - First Name:SHANDAREDA
Other - Middle Name:CHANTAY
Other - Last Name:SEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1100 JOHNSON FERRY RD STE 410
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-847-0664
Mailing Address - Fax:404-250-1694
Practice Address - Street 1:1100 JOHNSON FERRY RD STE 410
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1709
Practice Address - Country:US
Practice Address - Phone:404-847-0664
Practice Address - Fax:404-250-1694
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004742363A00000X, 364SP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP1700XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerinatal
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant