Provider Demographics
NPI:1598404055
Name:MANTOOTH, MACY ALEXANDRA (PA-C)
Entity type:Individual
Prefix:MS
First Name:MACY
Middle Name:ALEXANDRA
Last Name:MANTOOTH
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 TOWER RD NE STE 300
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9408
Mailing Address - Country:US
Mailing Address - Phone:770-427-2457
Mailing Address - Fax:
Practice Address - Street 1:355 TOWER RD NE STE 300
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9408
Practice Address - Country:US
Practice Address - Phone:770-427-2457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12344363A00000X
GA12607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant