Provider Demographics
NPI:1114004405
Name:SIGMON, TANYA L (PA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:SIGMON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 WALNUT AVE SW
Mailing Address - Street 2:APT #3
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4620
Mailing Address - Country:US
Mailing Address - Phone:540-915-6576
Mailing Address - Fax:
Practice Address - Street 1:3707 BRAMBLETON AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3658
Practice Address - Country:US
Practice Address - Phone:540-725-7800
Practice Address - Fax:540-989-6752
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002416363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010349486Medicaid
VA018095C18Medicare PIN
012235C99Medicare PIN