Healthcare Provider Details

I. General information

NPI: 1215054853
Provider Name (Legal Business Name): JAMES V WALDRON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 MEDICAL PARK DR
AUSTELL GA
30106-1110
US

IV. Provider business mailing address

3820 MEDICAL PARK DR
AUSTELL GA
30106-1110
US

V. Phone/Fax

Practice location:
  • Phone: 770-948-6041
  • Fax: 770-739-5411
Mailing address:
  • Phone: 770-948-6041
  • Fax: 770-739-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004817
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: