Provider Demographics
NPI:1508963315
Name:TALLEY, PAMELA A (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:TALLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:A
Other - Last Name:TALLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2299 9TH AVENUE NORTH
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713
Mailing Address - Country:US
Mailing Address - Phone:727-328-1841
Mailing Address - Fax:727-328-2640
Practice Address - Street 1:2299 9TH AVENUE NORTH
Practice Address - Street 2:SUITE 1D
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713
Practice Address - Country:US
Practice Address - Phone:727-328-1841
Practice Address - Fax:727-328-2640
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51658207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
04579OtherBLUE SHIELD
FL04579AMedicare ID - Type Unspecified
D51057Medicare UPIN