Provider Demographics
NPI:1760434872
Name:MUSTELIER, TERESA (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MUSTELIER
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 1:204 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2418
Mailing Address - Country:US
Mailing Address - Phone:770-779-0015
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002319363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001328AMedicaid
GA100001328BMedicaid
GA333580OtherWELLCARE
GA100001328Medicaid
GA10043470OtherAMERIGROUP
GA204856OtherBCBS
GA10043470OtherAMERIGROUP
GA333580OtherWELLCARE
GA97BBHBRMedicare ID - Type Unspecified
GA100001328BMedicaid