Provider Demographics
NPI:1902629611
Name:ALLEN, WESLEY RYAN
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:RYAN
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 TEXEL LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-2735
Mailing Address - Country:US
Mailing Address - Phone:706-564-5773
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTURY PKWY NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3125
Practice Address - Country:US
Practice Address - Phone:404-282-3632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-02
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant