Provider Demographics
NPI:1356586218
Name:TRAMMELL, MICHAEL ANTHONY (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:TRAMMELL
Suffix:
Gender:M
Credentials:PTA
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 431
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-0431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 PEARL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-7509
Practice Address - Country:US
Practice Address - Phone:770-748-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-06
Last Update Date:2008-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001345225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant