Provider Demographics
NPI:1770323305
Name:WALTERS, ALYSSA GRAHAM (PAC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:GRAHAM
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 N PARK TRL STE B
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7372
Mailing Address - Country:US
Mailing Address - Phone:770-507-0909
Mailing Address - Fax:770-507-1919
Practice Address - Street 1:150 N PARK TRL STE B
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7372
Practice Address - Country:US
Practice Address - Phone:770-507-0909
Practice Address - Fax:770-507-1919
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0000363A00000X
GA12418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant