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General NPI Number Information
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NPI Number | 1932426210
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Entity Type | Individual
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Provider Name | TEKLEWOLD H LAKE PA-C
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Gender | Male
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Dates
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Enumeration Date | 04/27/2010
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Last Update Date | 04/27/2010
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Provider Practice Location Address
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Address Line | 2830 CLEARVIEW PL SUITE 500
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City | DORAVILLE
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State | GA
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Zip | 30340-2134
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Country | US
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Telephone | 678-638-0888
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Fax | 678-507-2360
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Provider Business Mailing Address
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Address Line | 2830 CLEARVIEW PL SUITE 500
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City | DORAVILLE
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State | GA
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Zip | 30340-2134
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Country | US
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Telephone | 678-638-0888
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Fax | 678-507-2360
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 005767
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License Number State | GA
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