Healthcare Provider Details

I. General information

NPI: 1245540566
Provider Name (Legal Business Name): EMMALYN V. TAGUE PHYSICIAN ASSOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78TH MEDICAL GROUP 655 SEVENTH ST
ROBINS AFB GA
31098
US

IV. Provider business mailing address

78TH MEDICAL GROUP 655 SEVENTH ST
ROBINS AFB GA
31098
US

V. Phone/Fax

Practice location:
  • Phone: 478-327-8487
  • Fax:
Mailing address:
  • Phone: 478-327-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: