Basic Information
| Provider Information | |||||||||
| NPI: | 1083179493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE STE 160 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705904180 | ||||||||
| FaxNumber: | 7705904186 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 PEACHTREE STREET | ||||||||
| Address2: | DAVIS FISCHER BUILDING, OFFICE 3245A | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068892918 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2019 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.