Basic Information
| Provider Information | |||||||||
| NPI: | 1710290218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELSTAD | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NCCPA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHARRON | ||||||||
| OtherFirstName: | ADRIENNE | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NCCPA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3400 OLD MILTON PKWY # C | ||||||||
| Address2: | STE 290 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300053707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706674337 | ||||||||
| FaxNumber: | 7706674338 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 JOHNSON FERRY RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529063 | ||||||||
| FaxNumber: | 4042520873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 02/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 005700 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 749565882E | 05 | GA | MEDICAID | 749565882G | 05 | GA | MEDICAID | 749565882F | 05 | GA | MEDICAID |