Basic Information
| Provider Information | |||||||||
| NPI: | 1932669009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEITLER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 GLEASON AVE | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313221829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083729556 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2021 SCOTT RD | ||||||||
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| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309062539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067931057 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2019 | ||||||||
| LastUpdateDate: | 03/23/2019 | ||||||||
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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 | 225200000X | PTA003607 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | PTA003607 | 01 | GA | GA BOARD PHYSICAL THERAPY | OTHER |