MEDICARE: SALLIE LYNN STALEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	001000117	NC
2	363A00000X	Physician Assistant	0010-00117	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821068768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLIE LYNN STALEY PA-C

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1908 CAUDLE DR STE 200
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-4322
Country	:	US
Telephone Number	:	336-783-6935
Fax Number	:	336-783-6934

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	09/22/2022

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