Basic Information
Provider Information | |||||||||
NPI: | 1104023498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALL | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | MARK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA - C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3686 WHEELER RD | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309096520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7069226300 | ||||||||
FaxNumber: | 7069226303 | ||||||||
Practice Location | |||||||||
Address1: | 3686 WHEELER RD | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309096520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7069226300 | ||||||||
FaxNumber: | 7069226303 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2007 | ||||||||
LastUpdateDate: | 02/21/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1550 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | 1550 | GA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 101891268E | 05 | GA |   | MEDICAID | 101891268F | 05 | GA |   | MEDICAID | 101891268B | 05 | GA |   | MEDICAID | 101891268C | 05 | GA |   | MEDICAID | 101891268G | 05 | GA |   | MEDICAID | 0540PA | 05 | SC |   | MEDICAID | 101891268D | 05 | GA |   | MEDICAID |