Provider Demographics
NPI:1053652271
Name:SOFIANOS, TALLEY S (PA-C)
Entity Type:Individual
Prefix:
First Name:TALLEY
Middle Name:S
Last Name:SOFIANOS
Suffix:
Gender:F
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 1:14557 HIGHWAY 19 STE A
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-9582
Mailing Address - Country:US
Mailing Address - Phone:678-688-1580
Mailing Address - Fax:678-688-1594
Practice Address - Street 1:8832 US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-8932
Practice Address - Country:US
Practice Address - Phone:251-289-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006755363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid