Provider Demographics
NPI:1336616143
Name:SANFORD, DYLLON (PA-C)
Entity Type:Individual
Prefix:
First Name:DYLLON
Middle Name:
Last Name:SANFORD
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 1:105 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-3133
Mailing Address - Country:US
Mailing Address - Phone:903-392-8259
Mailing Address - Fax:903-657-1674
Practice Address - Street 1:105 N HIGH ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-3133
Practice Address - Country:US
Practice Address - Phone:033-928-2599
Practice Address - Fax:903-657-1674
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant