Healthcare Provider Details

I. General information

NPI: 1124505987
Provider Name (Legal Business Name): CAROLINE WOLTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 JOHNS CREEK PKWY
SUWANEE GA
30024-6038
US

IV. Provider business mailing address

378 VISTA LAKE DR
SUWANEE GA
30024-7420
US

V. Phone/Fax

Practice location:
  • Phone: 770-442-1911
  • Fax:
Mailing address:
  • Phone: 706-536-9094
  • 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: