Basic Information
| Provider Information | |||||||||
| NPI: | 1609174093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | Q. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709442830 | ||||||||
| FaxNumber: | 6785817170 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MARKET PLACE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301218718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703867253 | ||||||||
| FaxNumber: | 7703826424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 06/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 006066 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1609174093 | 01 | GA | NPI NUMBER | OTHER |