Healthcare Provider Details

I. General information

NPI: 1033865001
Provider Name (Legal Business Name): MADELINE TULLY URWIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 160
MARIETTA GA
30060-1160
US

IV. Provider business mailing address

609 VIRGINIA AVE NE APT 2405
ATLANTA GA
30306-3751
US

V. Phone/Fax

Practice location:
  • Phone: 770-428-0462
  • Fax: 770-427-8001
Mailing address:
  • Phone: 770-688-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10894
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: