Provider Demographics
NPI:1912668799
Name:WISE, ASHLEY D (PAC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:D
Last Name:WISE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
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:2022-01-04
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10682363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant