Healthcare Provider Details

I. General information

NPI: 1598814469
Provider Name (Legal Business Name): MARLA TEAT DIXON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLA FAITH TEAT PA

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 LIMESTONE OVERLOOK
GAINESVILLE GA
30501-7443
US

IV. Provider business mailing address

2324 LIMESTONE OVERLOOK
GAINESVILLE GA
30501-7443
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-8109
  • Fax: 770-536-3203
Mailing address:
  • Phone: 770-536-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004138
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004138
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: