Provider Demographics
NPI:1952512022
Name:HARLOS, TODD EDWARD (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:EDWARD
Last Name:HARLOS
Suffix:
Gender:M
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 1:2060 DAN PROCTOR DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3895
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2060 DAN PROCTOR DR STE 2100
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3895
Practice Address - Country:US
Practice Address - Phone:912-882-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant