Basic Information
| Provider Information | |||||||||
| NPI: | 1861477648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGBULOS | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C, AA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18824 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274198824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 DARLING AVE | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315015246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123386511 | ||||||||
| FaxNumber: | 9123386512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 02/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA16336 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 005073 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367H00000X | 005073 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 259983019A | 05 | GA | MEDICAID | P00410142 | 01 | GA | RRB | OTHER | PA16336 | 05 | CA | MEDICAID |