Provider Demographics
NPI:1821068768
Name:STALEY, SALLIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:LYNN
Last Name:STALEY
Suffix:
Gender:F
Credentials:PA-C
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1908 CAUDLE DR STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4322
Practice Address - Country:US
Practice Address - Phone:336-783-6935
Practice Address - Fax:336-783-6934
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000117363AM0700X
NC0010-00117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101699Medicaid
NC2764227BMedicare PIN
Q52264Medicare UPIN
NC2764227Medicare PIN