Healthcare Provider Details

I. General information

NPI: 1871577395
Provider Name (Legal Business Name): STEPHEN E GALYA PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 STILESBORO RD NW STE 120
KENNESAW GA
30152
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 678-354-0230
  • Fax: 678-354-0828
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5141
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0001524
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: