Provider Demographics
NPI:1689966608
Name:STANDIFORD, DARRON S (PA)
Entity Type:Individual
Prefix:MR
First Name:DARRON
Middle Name:S
Last Name:STANDIFORD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:602 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4913
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-7850
Practice Address - Street 1:5354 REYNOLDS ST STE 102
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6008
Practice Address - Country:US
Practice Address - Phone:912-819-0500
Practice Address - Fax:912-819-0501
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006105363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6105OtherGEORGIA MEDICAL LICENSE
GA003109818EMedicaid
GAP0164222OtherRAILRAOD MEDICARE
SC1183PAMedicaid