Provider Demographics
NPI:1578616868
Name:MARTIN, TERENCE MALLOY (PA-C)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:MALLOY
Last Name:MARTIN
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 1:1600 FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1408
Mailing Address - Country:US
Mailing Address - Phone:478-743-3000
Mailing Address - Fax:
Practice Address - Street 1:1600 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1408
Practice Address - Country:US
Practice Address - Phone:478-743-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002814AMedicaid
GA100002814AMedicaid