Provider Demographics
NPI:1518918549
Name:MARSH, NATHAN MCKENZIE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:MCKENZIE
Last Name:MARSH
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:1404 RIVER PL STE 401
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517
Practice Address - Country:US
Practice Address - Phone:770-848-6190
Practice Address - Fax:770-848-5367
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004526363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA536570372BMedicaid
GA536570372BMedicaid
GA97WCHVHMedicare PIN