Provider Demographics
NPI:1962487538
Name:LIDELL, JOHN MARK (MMSC , PA-C)
Entity type:Individual
Prefix:PROF
First Name:JOHN
Middle Name:MARK
Last Name:LIDELL
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Gender:M
Credentials:MMSC , PA-C
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Mailing Address - Street 1:3576 HIGHWAY 138 SE
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7909
Mailing Address - Country:US
Mailing Address - Phone:770-474-7448
Mailing Address - Fax:770-474-7194
Practice Address - Street 1:101 REGENCY PARK DR STE 110
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7076
Practice Address - Country:US
Practice Address - Phone:404-996-0126
Practice Address - Fax:678-432-2626
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-10-27
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Provider Licenses
StateLicense IDTaxonomies
GA002952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant