Provider Demographics
NPI:1932305810
Name:MOORE, CHASKA LASHAWN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHASKA
Middle Name:LASHAWN
Last Name:MOORE
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 1:750 MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3002
Mailing Address - Country:US
Mailing Address - Phone:770-778-9004
Mailing Address - Fax:
Practice Address - Street 1:750 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3002
Practice Address - Country:US
Practice Address - Phone:770-960-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant