Basic Information
| Provider Information | |||||||||
| NPI: | 1720060122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | FREDERICK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1950 | ||||||||
| Address2: | |||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301331950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066608505 | ||||||||
| FaxNumber: | 7066609390 | ||||||||
| Practice Location | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707940477 | ||||||||
| FaxNumber: | 7707943108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 002844 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367H00000X | 2844 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 640402698A | 05 | GA | MEDICAID | 491431789A | 05 | GA | MEDICAID |