Provider Demographics
NPI:1205824760
Name:SACKARIASEN, PHYLLIS WRENN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:WRENN
Last Name:SACKARIASEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:WRENN
Other - Last Name:SLOAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3090 SUGAR VALLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:SUGAR VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30746-5166
Mailing Address - Country:US
Mailing Address - Phone:706-624-4661
Mailing Address - Fax:706-624-4698
Practice Address - Street 1:3090 SUGAR VALLEY RD NW
Practice Address - Street 2:
Practice Address - City:SUGAR VALLEY
Practice Address - State:GA
Practice Address - Zip Code:30746-5166
Practice Address - Country:US
Practice Address - Phone:706-624-4661
Practice Address - Fax:706-624-4698
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA236050967AMedicaid
GAMS0716677OtherDEA
97BBHHBMedicare ID - Type Unspecified
P42067Medicare UPIN