Provider Demographics
NPI:1689624397
Name:MARBURY, WILLIAM A (PAA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:MARBURY
Suffix:
Gender:M
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 CHIMNEY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1446
Mailing Address - Country:US
Mailing Address - Phone:404-849-9450
Mailing Address - Fax:
Practice Address - Street 1:303 PARKWAY DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:404-265-4520
Practice Address - Fax:404-265-3894
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004644363AM0700X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAN345536OtherWELLCARE
P00301548OtherRAILROAD MEDICARE
GA782557551BMedicaid
GA782557551CMedicaid
GA782557551AMedicaid
GA782557551CMedicaid
GA782557551AMedicaid