Provider Demographics
NPI:1124184742
Name:FRANKLIN, MARA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:RENEE
Last Name:FRANKLIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:RENEE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0011
Mailing Address - Country:US
Mailing Address - Phone:706-769-6469
Mailing Address - Fax:706-769-4402
Practice Address - Street 1:1450 BARNETT SHOALS RD STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-2748
Practice Address - Country:US
Practice Address - Phone:706-543-6443
Practice Address - Fax:706-543-8202
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA072415793CMedicaid
GA072415793BMedicaid
GA072415793AMedicaid
GA072415793CMedicaid
GA072415793AMedicaid
P00417347Medicare PIN
GA97WCJXNMedicare PIN