Basic Information
| Provider Information | |||||||||
| NPI: | 1255628533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIGGINS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-AA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOKE | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-AA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2608 DREW VALLEY RD NE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303193928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045785860 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE RD., NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 006200 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003113410A | 05 | GA | MEDICAID |