Healthcare Provider Details

I. General information

NPI: 1073571410
Provider Name (Legal Business Name): PAUL WOLKOFF ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BOBBY DODD WAY
ATLANTA GA
30332-0001
US

IV. Provider business mailing address

2909 HAMILTON SQ
DECATUR GA
30033-1140
US

V. Phone/Fax

Practice location:
  • Phone: 404-894-8122
  • Fax: 404-894-0695
Mailing address:
  • Phone: 404-633-6390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number502
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: