Basic Information
| Provider Information | |||||||||
| NPI: | 1295077899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANDYA | ||||||||
| FirstName: | MAMTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 15TH ST # OR6000 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067213813 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309123013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067218623 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2013 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5015313 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 03518 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | GAA-NP000553 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.