Provider Demographics
NPI:1255628533
Name:WIGGINS, AMANDA DEAN (PA-AA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DEAN
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:PA-AA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:D
Other - Last Name:COOKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-AA
Mailing Address - Street 1:2608 DREW VALLEY RD NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3928
Mailing Address - Country:US
Mailing Address - Phone:404-578-5860
Mailing Address - Fax:
Practice Address - Street 1:1968 PEACHTREE RD., NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006200367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113410AMedicaid
GA202I320679Medicare PIN