=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275087371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA SANDWICH PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2016
-----------------------------------------------------
Last Update Date | 03/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 LANIER AVE WEST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-460-8988
-----------------------------------------------------
Fax | 770-460-0727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 LANIER AVE WEST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-460-8988
-----------------------------------------------------
Fax | 770-460-0727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 8052
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------