Basic Information
| Provider Information | |||||||||
| NPI: | 1245894427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | AUSTIN | ||||||||
| MiddleName: | TODEY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TODEY | ||||||||
| OtherFirstName: | AUSTIN | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1439 CHESHIRE WAY NE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303193159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702892320 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3400 OLD MILTON PKWY STE C290 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300056491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706674343 | ||||||||
| FaxNumber: | 7707720937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2019 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 00000 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.