Individual
TEKLEWOLD H LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2830 CLEARVIEW PL, SUITE 500, DORAVILLE, GA 30340-2134
(678) 638-0888
(678) 507-2360
Mailing address
2830 CLEARVIEW PL, SUITE 500, DORAVILLE, GA 30340-2134
(678) 638-0888
(678) 507-2360
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
005767
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
005767
GEORGIA LICENSE
GA
Enumeration date
04/27/2010
Last updated
04/27/2010
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