Provider Demographics
NPI:1164988143
Name:COLON, AMY THEOBALD (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:THEOBALD
Last Name:COLON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 OLD MILTON PKWY STE C270
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4414
Mailing Address - Country:US
Mailing Address - Phone:704-421-9117
Mailing Address - Fax:
Practice Address - Street 1:3400C OLD MILTON PKWY STE 270
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4438
Practice Address - Country:US
Practice Address - Phone:770-442-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9156363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical