Provider Demographics
NPI:1083179493
Name:MARTIN, THOMAS KENNETH II (PA-C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:KENNETH
Last Name:MARTIN
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE STE 160
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1160
Mailing Address - Country:US
Mailing Address - Phone:770-590-4180
Mailing Address - Fax:770-590-4186
Practice Address - Street 1:550 PEACHTREE STREET
Practice Address - Street 2:DAVIS FISCHER BUILDING, OFFICE 3245A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308
Practice Address - Country:US
Practice Address - Phone:706-889-2918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-10
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant