Provider Demographics
NPI:1174841647
Name:THAXTON, MARIAH WOOD (PA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:WOOD
Last Name:THAXTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 STONE SHOALS CT
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-2774
Mailing Address - Country:US
Mailing Address - Phone:478-457-7128
Mailing Address - Fax:
Practice Address - Street 1:821 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2343
Practice Address - Country:US
Practice Address - Phone:478-457-7128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-08
Last Update Date:2010-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant