Provider Demographics
NPI:1639154040
Name:MARTIN, SCOTT A (PA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA
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 409
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0011
Mailing Address - Country:US
Mailing Address - Phone:706-769-6469
Mailing Address - Fax:706-769-4402
Practice Address - Street 1:1550 MARS HILL RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-4836
Practice Address - Country:US
Practice Address - Phone:706-769-4852
Practice Address - Fax:706-769-8372
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ59824Medicare UPIN
GA97WCHFCMedicare ID - Type Unspecified