Basic Information
| Provider Information | |||||||||
| NPI: | 1164988143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | THEOBALD | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 OLD MILTON PKWY STE C270 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044219117 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3400C OLD MILTON PKWY STE 270 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704421911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2019 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9156 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.