Healthcare Provider Details

I. General information

NPI: 1124027685
Provider Name (Legal Business Name): MARK ALAN HARTLEY MPAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 MARTIN LOOP MARTIN ARMY COMMUNITY HOSPITAL
FORT BENNING GA
31905-5647
US

IV. Provider business mailing address

1063 LEE ROAD 338
SALEM AL
36874-1219
US

V. Phone/Fax

Practice location:
  • Phone: 706-545-8543
  • Fax:
Mailing address:
  • Phone: 706-761-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1033608
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: