Provider Demographics
NPI:1174872980
Name:WALFRIDSON, SYLVIA (PA)
Entity type:Individual
Prefix:MRS
First Name:SYLVIA
Middle Name:
Last Name:WALFRIDSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 HILLGROVE DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-6806
Mailing Address - Country:US
Mailing Address - Phone:203-249-9007
Mailing Address - Fax:
Practice Address - Street 1:1043 OLD PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043
Practice Address - Country:US
Practice Address - Phone:678-335-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8578363A00000X
CT002802363A00000X
NY015975363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03753564Medicaid
NYA400111277Medicare UPIN