Provider Demographics
NPI:1245540566
Name:TAGUE, EMMALYN V (PHYSICIAN ASSOCIATE)
Entity type:Individual
Prefix:MISS
First Name:EMMALYN
Middle Name:V
Last Name:TAGUE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78TH MEDICAL GROUP
Mailing Address - Street 2:655 SEVENTH ST
Mailing Address - City:ROBINS AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31098
Mailing Address - Country:US
Mailing Address - Phone:478-327-8487
Mailing Address - Fax:
Practice Address - Street 1:78TH MEDICAL GROUP
Practice Address - Street 2:655 SEVENTH ST
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098
Practice Address - Country:US
Practice Address - Phone:478-327-8487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider