Healthcare Provider Details

I. General information

NPI: 1962037556
Provider Name (Legal Business Name): HALI WOLF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

PO BOX 3548
AUGUSTA GA
30914-3548
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9595
  • Fax: 706-868-8375
Mailing address:
  • Phone: 706-863-9595
  • Fax: 706-447-7184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9956
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007395
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006061
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: