Provider Demographics
NPI:1598814469
Name:DIXON, MARLA TEAT (PA-C)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:TEAT
Last Name:DIXON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:FAITH
Other - Last Name:TEAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2324 LIMESTONE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-7443
Mailing Address - Country:US
Mailing Address - Phone:770-536-8109
Mailing Address - Fax:
Practice Address - Street 1:2324 LIMESTONE OVERLOOK
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7443
Practice Address - Country:US
Practice Address - Phone:770-536-8109
Practice Address - Fax:770-536-3203
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004138363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA654547969AMedicaid
GA654547969AMedicaid
GA97WCFCNMedicare ID - Type Unspecified