Healthcare Provider Details

I. General information

NPI: 1720072010
Provider Name (Legal Business Name): SUGIARTO TJEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 CENTER ST
COLUMBUS GA
31901-1527
US

IV. Provider business mailing address

PO BOX 1380
COLUMBUS GA
31902-1307
US

V. Phone/Fax

Practice location:
  • Phone: 706-571-1374
  • Fax: 706-660-2686
Mailing address:
  • Phone: 706-571-1374
  • Fax: 706-660-2686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0002104
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2104
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: