Healthcare Provider Details

I. General information

NPI: 1932676681
Provider Name (Legal Business Name): ASHLEY KING WAFFORD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

955 JUNIPER ST NE UNIT 3028
ATLANTA GA
30309-5117
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-1000
  • Fax:
Mailing address:
  • Phone: 678-895-8084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: