Provider Demographics
NPI:1285108183
Name:POLASCIK, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:POLASCIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5925
Mailing Address - Country:US
Mailing Address - Phone:770-237-3475
Mailing Address - Fax:770-237-3756
Practice Address - Street 1:2801 N DECATUR RD STE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5936
Practice Address - Country:US
Practice Address - Phone:404-296-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty