Healthcare Provider Details

I. General information

NPI: 1356063341
Provider Name (Legal Business Name): SI WOO AN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 PEACHTREE INDUSTRIAL BLVD STE 100
DULUTH GA
30096-5139
US

IV. Provider business mailing address

3 WILD TURKEY LN
ROCK TAVERN NY
12575-5419
US

V. Phone/Fax

Practice location:
  • Phone: 678-417-0332
  • Fax:
Mailing address:
  • Phone: 201-364-8465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: