Provider Demographics
NPI:1922081330
Name:MARSHALL, TAMARA LYNN (PAAA)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 NEW NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:770-874-5400
Mailing Address - Fax:770-874-6897
Practice Address - Street 1:8954 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:770-920-6413
Practice Address - Fax:678-838-2532
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002716363A00000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA491431789AMedicaid
GA199727917AMedicaid
GA199727917AMedicaid
GA491431789AMedicaid