Provider Demographics
NPI:1720060122
Name:ALLEN, CHRISTIAN FREDERICK (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:FREDERICK
Last Name:ALLEN
Suffix:
Gender:M
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:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-1950
Mailing Address - Country:US
Mailing Address - Phone:706-660-8505
Mailing Address - Fax:706-660-9390
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:770-794-3108
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002844363A00000X
GA2844367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA640402698AMedicaid
GA491431789AMedicaid
GA6182Medicare ID - Type UnspecifiedGROUP