Provider Demographics
NPI:1568752830
Name:WAKEFIELD, DON RICK (PA)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:RICK
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3657 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-7610
Mailing Address - Country:US
Mailing Address - Phone:770-926-0062
Mailing Address - Fax:
Practice Address - Street 1:3657 CANTON RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-7610
Practice Address - Country:US
Practice Address - Phone:770-926-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA02349111N00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No111N00000XChiropractic ProvidersChiropractor