Provider Demographics
NPI:1982698361
Name:CARTER, DUSTIN J (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:J
Last Name:CARTER
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8907
Mailing Address - Country:US
Mailing Address - Phone:912-537-9851
Mailing Address - Fax:912-537-9843
Practice Address - Street 1:200 MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8907
Practice Address - Country:US
Practice Address - Phone:912-537-9851
Practice Address - Fax:912-537-9843
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003872363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA683347114AMedicaid
GA581356947OtherPRACTICE FEDERAL TAX ID
GAP69263Medicare UPIN
GA581356947OtherPRACTICE FEDERAL TAX ID