Basic Information
| Provider Information | |||||||||
| NPI: | 1982991691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHUFORD | ||||||||
| FirstName: | CARLTON | ||||||||
| MiddleName: | JOSHUA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 WHITCHER ST NE | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704223290 | ||||||||
| FaxNumber: | 7704220287 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 WHITCHER ST NE | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704223290 | ||||||||
| FaxNumber: | 7704220287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 006165 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 006165 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003143723A | 05 | GA | MEDICAID | 003143723C | 05 | GA | MEDICAID | 003143723D | 05 | GA | MEDICAID |