Provider Demographics
NPI:1063795409
Name:NOLD, CARRIE SMITH (PA-C)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:SMITH
Last Name:NOLD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 OLD PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2937
Mailing Address - Country:US
Mailing Address - Phone:770-682-2362
Mailing Address - Fax:
Practice Address - Street 1:625 OLD PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2937
Practice Address - Country:US
Practice Address - Phone:770-682-2362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1681363A00000X
GA7799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant