Provider Demographics
NPI:1861477648
Name:AGBULOS, STANLEY A (PA-C, AA-C)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:A
Last Name:AGBULOS
Suffix:
Gender:M
Credentials:PA-C, AA-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 18824
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27419-8824
Mailing Address - Country:US
Mailing Address - Phone:336-553-1659
Mailing Address - Fax:336-553-3994
Practice Address - Street 1:410 DARLING AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5246
Practice Address - Country:US
Practice Address - Phone:912-338-6511
Practice Address - Fax:912-338-6512
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16336363A00000X
GA005073363A00000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA259983019AMedicaid
GAP00410142OtherRRB
CAPA16336Medicaid
GA32BBCGDMedicare PIN
GAP00410142Medicare PIN
OPA163360Medicare ID - Type Unspecified