Basic Information
| Provider Information | |||||||||
| NPI: | 1992920110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12938 | ||||||||
| Address2: | C/O CLINIC MANAGEMENT | ||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30703 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 TIMMS RD NE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307017016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066023100 | ||||||||
| FaxNumber: | 7066023101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2007 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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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 | 2255A2300X | AT0671 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 5822 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 361360414D | 05 | GA | MEDICAID |