Provider Demographics
NPI:1801164389
Name:WADUD, MIR ABDUL (NP)
Entity type:Individual
Prefix:MR
First Name:MIR
Middle Name:ABDUL
Last Name:WADUD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 WILLOWMERE TRCE NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6182
Mailing Address - Country:US
Mailing Address - Phone:678-446-1473
Mailing Address - Fax:
Practice Address - Street 1:1758 COUNTY SERVICES PKWY SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4012
Practice Address - Country:US
Practice Address - Phone:404-794-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA210808363LF0000X
NCRN250110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily