Provider Demographics
NPI:1265477186
Name:EARNHARDT, MARION MCCAULEY (PA)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:MCCAULEY
Last Name:EARNHARDT
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 1:2650 GENTRY WALK CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7484
Mailing Address - Country:US
Mailing Address - Phone:770-722-1940
Mailing Address - Fax:
Practice Address - Street 1:5115 NEW PEACHTREE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-3326
Practice Address - Country:US
Practice Address - Phone:678-672-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003245363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCHLHMedicare ID - Type Unspecified
GAS72498Medicare UPIN