Provider Demographics
NPI:1972726065
Name:NIXON, SARA MARIE (PTA 002602)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:NIXON
Suffix:
Gender:F
Credentials:PTA 002602
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 RIDGE CROSSING DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189
Mailing Address - Country:US
Mailing Address - Phone:706-951-5103
Mailing Address - Fax:
Practice Address - Street 1:1539 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1306
Practice Address - Country:US
Practice Address - Phone:304-363-8479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002602225200000X
WVPTA 001284225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1972726065Medicaid
GA1972726065Medicaid