Provider Demographics
NPI:1770502585
Name:MILLSAPS, TONYA MEADOWS (PA)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:MEADOWS
Last Name:MILLSAPS
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:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:704-978-3549
Practice Address - Street 1:393 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28681-4180
Practice Address - Country:US
Practice Address - Phone:704-871-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMM0258930OtherDEA - NC
NCP10068Medicare UPIN
NC2752886AMedicare Oscar/Certification
NC2752886Medicare ID - Type UnspecifiedMEDICARE NC