Provider Demographics
NPI:1780620930
Name:MCKENNA, ROBERT MARTIN JR (PA C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MARTIN
Last Name:MCKENNA
Suffix:JR
Gender:M
Credentials:PA C
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Mailing Address - Street 1:5667 PEACHTREE DUNWOODY RD, NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1725
Mailing Address - Country:US
Mailing Address - Phone:404-252-7200
Mailing Address - Fax:404-252-7397
Practice Address - Street 1:5667 PEACHTREE DUNWOODY RD, NE
Practice Address - Street 2:SUITE 350
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1725
Practice Address - Country:US
Practice Address - Phone:404-252-7200
Practice Address - Fax:404-252-7397
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-08-12
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Provider Licenses
StateLicense IDTaxonomies
SCA676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0033PAMedicaid
P09681Medicare UPIN
SCP096818619Medicare PIN