1366409583 NPI number — MISS KIMBERLY MICHELLE WAHLER PA-C

Table of content: MISS KIMBERLY MICHELLE WAHLER PA-C (NPI 1366409583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366409583 NPI number — MISS KIMBERLY MICHELLE WAHLER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAHLER
Provider First Name:
KIMBERLY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FUNG
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366409583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
183 3RD AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30317-2705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-409-5461
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5505 PEACHTREE DUNWOODY RD NE
Provider Second Line Business Practice Location Address:
STE. 410
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-250-3333
Provider Business Practice Location Address Fax Number:
404-250-0175
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  004784 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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