Provider Demographics
NPI:1366409583
Name:WAHLER, KIMBERLY MICHELLE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:WAHLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:FUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:183 3RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30317-2705
Mailing Address - Country:US
Mailing Address - Phone:813-409-5461
Mailing Address - Fax:
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:STE. 410
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1705
Practice Address - Country:US
Practice Address - Phone:404-250-3333
Practice Address - Fax:404-250-0175
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004784363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN