Provider Demographics
NPI:1245866276
Name:BROADWATER, ALYSSA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:731 PAINT HORSE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-6817
Mailing Address - Country:US
Mailing Address - Phone:386-405-8814
Mailing Address - Fax:
Practice Address - Street 1:5665 PEACHTREE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1764
Practice Address - Country:US
Practice Address - Phone:404-778-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-21
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical