Provider Demographics
NPI:1811961345
Name:TOLBERT, JOHN MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:TOLBERT
Suffix:
Gender:M
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 1:157 CLINIC AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4413
Mailing Address - Country:US
Mailing Address - Phone:770-838-9333
Mailing Address - Fax:770-838-7755
Practice Address - Street 1:157 CLINIC AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4413
Practice Address - Country:US
Practice Address - Phone:770-838-9333
Practice Address - Fax:770-838-7755
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCHGWMedicare ID - Type UnspecifiedMEDICARE #
GAQ62363Medicare UPIN