Provider Demographics
NPI:1538111539
Name:WALLANG, LUCY (PA)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:WALLANG
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 1:2545 ALEXA CHASE CV
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7578
Mailing Address - Country:US
Mailing Address - Phone:770-866-5147
Mailing Address - Fax:
Practice Address - Street 1:4646 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6308
Practice Address - Country:US
Practice Address - Phone:770-866-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004665363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA723874491AMedicaid
GA01076922OtherAMERIGROUP
GA11143OtherBLUE CROSS BLUE SHIELD
GA723874491Medicaid
GA333656OtherWELLCARE
GA723874491BMedicaid
GA723874491BMedicaid
GA723874491AMedicaid