Provider Demographics
NPI:1033865001
Name:TULLY, MADELINE (PA-C)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
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 1:609 VIRGINIA AVE NE APT 2405
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3751
Mailing Address - Country:US
Mailing Address - Phone:770-688-5404
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER ST NE STE 160
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1160
Practice Address - Country:US
Practice Address - Phone:770-428-0462
Practice Address - Fax:770-427-8001
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1192347OtherNCCPA ID NUMBER