Provider Demographics
NPI:1346590023
Name:ANDEREGG, CHRISTIE WELLS (PA - C)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:WELLS
Last Name:ANDEREGG
Suffix:
Gender:F
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 1:3020 HIGHWAY 124
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4614
Mailing Address - Country:US
Mailing Address - Phone:770-978-1331
Mailing Address - Fax:770-978-8580
Practice Address - Street 1:3020 HIGHWAY 124
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-4614
Practice Address - Country:US
Practice Address - Phone:770-978-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2367363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134851AMedicaid
202I978732Medicare PIN