Provider Demographics
NPI:1538714555
Name:WALD, ALISON NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:NICOLE
Last Name:WALD
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 1:204 LONGLEAF CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-1909
Mailing Address - Country:US
Mailing Address - Phone:770-851-9920
Mailing Address - Fax:
Practice Address - Street 1:790 CHURCH ST NE STE 150
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8950
Practice Address - Country:US
Practice Address - Phone:770-427-1471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant