Provider Demographics
NPI:1609212661
Name:WOODARD, LARESA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LARESA
Middle Name:M
Last Name:WOODARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LARESA
Other - Middle Name:M
Other - Last Name:NOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 PERIMETER PARK DR APT 343
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1344
Mailing Address - Country:US
Mailing Address - Phone:404-556-8906
Mailing Address - Fax:610-980-3473
Practice Address - Street 1:1422 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6983
Practice Address - Country:US
Practice Address - Phone:404-766-3337
Practice Address - Fax:404-766-1464
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA06771363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical