Healthcare Provider Details

I. General information

NPI: 1578125522
Provider Name (Legal Business Name): VINCENT TIMOTHY WALDRON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2019
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WHITCHER ST NE STE 3110
MARIETTA GA
30060-1179
US

IV. Provider business mailing address

61 WHITCHER ST NE STE 3110
MARIETTA GA
30060-1179
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-2326
  • Fax:
Mailing address:
  • Phone: 770-422-2326
  • Fax: 770-422-7231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66276
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number10208
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberPA66276
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: