MEDICARE: AGELESS MENS HEALTH

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	5765	GA

General Provider Information

NPI Number	:	1518281864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGELESS MENS HEALTH

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	:	602-796-2559
Fax Number	:

Provider Business Practice Location Address
First Line	:	2941 PIEDMONT RD NE
Second Line	:	SUITE B
City	:	ATLANTA
State	:	GA
Zip	:	30305-2784
Country	:	US
Telephone Number	:	404-841-9445
Fax Number	:	901-841-9446

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

Provider Enumeration Date	:	03/16/2010
Last Update Date	:	01/09/2026

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