Provider Demographics
NPI:1780265892
Name:MARTIN, GRIFFIN (PTA)
Entity type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 CAMELLIA WAY
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31639-2711
Mailing Address - Country:US
Mailing Address - Phone:229-300-6958
Mailing Address - Fax:
Practice Address - Street 1:405 LAUREL ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-3030
Practice Address - Country:US
Practice Address - Phone:229-543-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004121225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant