Provider Demographics
NPI:1083190706
Name:CHASTEEN, AUDREY (PA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:CHASTEEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 WELLBROOK CIR NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3872
Mailing Address - Country:US
Mailing Address - Phone:770-922-5458
Mailing Address - Fax:770-922-0435
Practice Address - Street 1:1370 WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3872
Practice Address - Country:US
Practice Address - Phone:177-092-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant