Healthcare Provider Details

I. General information

NPI: 1407215718
Provider Name (Legal Business Name): NANCY CHUNG PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD
AUSTELL GA
30106-1121
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 470-732-4000
  • Fax:
Mailing address:
  • Phone: 770-792-5451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4155
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7789
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: