Provider Demographics
NPI:1609843457
Name:LANGFORD, MARVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:LANGFORD
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 2547
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-0044
Mailing Address - Country:US
Mailing Address - Phone:706-258-2091
Mailing Address - Fax:
Practice Address - Street 1:175 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1964
Practice Address - Country:US
Practice Address - Phone:706-253-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2019-02-19
Deactivation Date:2018-05-07
Deactivation Code:
Reactivation Date:2019-02-19
Provider Licenses
StateLicense IDTaxonomies
GA5494363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN