Healthcare Provider Details

I. General information

NPI: 1972902666
Provider Name (Legal Business Name): NICHOLAS CARSTENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD
AUSTELL GA
30106-1121
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR SUITE 320
ATLANTA GA
30328-5831
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-3800
  • Fax:
Mailing address:
  • Phone: 770-874-6907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: