Provider Demographics
NPI:1932426210
Name:LAKE, TEKLEWOLD H (PA-C)
Entity type:Individual
Prefix:
First Name:TEKLEWOLD
Middle Name:H
Last Name:LAKE
Suffix:
Gender:M
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 1:2830 CLEARVIEW PL
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-2134
Mailing Address - Country:US
Mailing Address - Phone:678-638-0888
Mailing Address - Fax:678-507-2360
Practice Address - Street 1:2830 CLEARVIEW PL
Practice Address - Street 2:SUITE 500
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-2134
Practice Address - Country:US
Practice Address - Phone:678-638-0888
Practice Address - Fax:678-507-2360
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005767OtherGEORGIA LICENSE