Healthcare Provider Details

I. General information

NPI: 1801520564
Provider Name (Legal Business Name): MARYN HAYWARD DEYOUNG PA-C, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARYN BURNS HAYWARD PA-C, MPH

II. Dates (important events)

Enumeration Date: 07/10/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PONCE DE LEON AVE STE 110
DECATUR GA
30030-3467
US

IV. Provider business mailing address

200 E PONCE DE LEON AVE STE 110
DECATUR GA
30030-3467
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-6363
  • Fax:
Mailing address:
  • Phone: 404-501-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11451
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: