MEDICARE: AGELESS WOMEN'S HEALTH GA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1003785577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGELESS WOMEN'S HEALTH GA LLC

Provider Business Mailing Address
First Line	:	10501 W GOWAN RD STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 COMMERCE DR STE 300
Second Line	:
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-3582
Country	:	US
Telephone Number	:	602-796-2559
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS OPERATIONS DIRECTOR
Name	:	AMANDA WILKINSON
Credential	:
Telephone Number	:	602-796-2559

Provider Enumeration Date	:	11/03/2025
Last Update Date	:	11/03/2025

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