Provider Demographics
NPI:1588963490
Name:TYLER, SANDRA SULLIVAN (PAC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:SULLIVAN
Last Name:TYLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:Y
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3350 PADDOCKS PKWY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-9119
Mailing Address - Country:US
Mailing Address - Phone:678-735-5300
Mailing Address - Fax:678-735-5305
Practice Address - Street 1:3350 PADDOCKS PKWY
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-9119
Practice Address - Country:US
Practice Address - Phone:678-735-5300
Practice Address - Fax:678-735-5305
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3288363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical