Healthcare Provider Details

I. General information

NPI: 1003607516
Provider Name (Legal Business Name): MADISON MANN HANCOCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CLINIC AVE STE 302C
CARROLLTON GA
30117-4454
US

IV. Provider business mailing address

157 CLINIC AVE STE 302C
CARROLLTON GA
30117-4454
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-3336
  • Fax: 770-832-2331
Mailing address:
  • Phone: 770-834-3336
  • Fax: 770-832-2331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13730
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: