Provider Demographics
NPI:1891338703
Name:CAVER, KOLYSE WAGSTAFF (PA-C)
Entity Type:Individual
Prefix:
First Name:KOLYSE
Middle Name:WAGSTAFF
Last Name:CAVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KOLYSE
Other - Middle Name:ELIZA
Other - Last Name:WAGSTAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1210 ROY RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1812
Mailing Address - Country:US
Mailing Address - Phone:706-860-6515
Mailing Address - Fax:706-860-1225
Practice Address - Street 1:1210 ROY RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1812
Practice Address - Country:US
Practice Address - Phone:706-860-6515
Practice Address - Fax:706-860-1225
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant