Basic Information
Provider Information | |||||||||
NPI: | 1215187711 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WIBERLEY | ||||||||
FirstName: | COLE | ||||||||
MiddleName: | BELTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAAA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3155 N POINT PKWY | ||||||||
Address2: | BUILDING F, SUITE 100 ATTN: CREDENTIALING | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300055481 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706459181 | ||||||||
FaxNumber: | 7706458455 | ||||||||
Practice Location | |||||||||
Address1: | 677 CHURCH ST NE | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707940477 | ||||||||
FaxNumber: | 7707943108 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2008 | ||||||||
LastUpdateDate: | 08/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 005429 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 444906161A | 05 | GA |   | MEDICAID |