Basic Information
| Provider Information | |||||||||
| NPI: | 1851973267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | MADISON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 LOVINGGOOD TRL | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301897413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048893189 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1495 HICKORY FLAT HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301154266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704421911 | ||||||||
| FaxNumber: | 6786267900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2021 | ||||||||
| LastUpdateDate: | 04/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.