Provider Demographics
NPI:1295205110
Name:SRODA, AUSTIN D (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:D
Last Name:SRODA
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 JOSHUA TREE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2791
Mailing Address - Country:US
Mailing Address - Phone:715-310-2145
Mailing Address - Fax:
Practice Address - Street 1:3109 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-3049
Practice Address - Country:US
Practice Address - Phone:706-737-1626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2255A2300X
GAAT0036862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer