Healthcare Provider Details

I. General information

NPI: 1639809353
Provider Name (Legal Business Name): CALEB I MARTINEZ LAZO CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

IV. Provider business mailing address

718 NIGHTWIND WAY
STOCKBRIDGE GA
30281-9134
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-7000
  • Fax:
Mailing address:
  • Phone: 678-978-0169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number11208
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: