Provider Demographics
NPI:1194495176
Name:ELLOWAY, AVERY LOUISE (PA-C)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:LOUISE
Last Name:ELLOWAY
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 1:2750 OWENS RD SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3991
Mailing Address - Country:US
Mailing Address - Phone:678-413-4644
Mailing Address - Fax:470-705-0074
Practice Address - Street 1:2750 OWENS RD SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3991
Practice Address - Country:US
Practice Address - Phone:678-413-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11573363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical