Provider Demographics
NPI:1083803068
Name:SPATZ, MARK M (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:SPATZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 BROOKSTONE CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2954
Mailing Address - Country:US
Mailing Address - Phone:706-322-1717
Mailing Address - Fax:706-322-1718
Practice Address - Street 1:1210 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-2954
Practice Address - Country:US
Practice Address - Phone:706-322-1717
Practice Address - Fax:706-322-1718
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA5199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I970047OtherMEDICARE RAILROAD
GA511I970047Medicare PIN