Provider Demographics
NPI:1447381959
Name:WOODSON, TANYA SUE (PAC)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:SUE
Last Name:WOODSON
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 OGBURN AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-2726
Mailing Address - Country:US
Mailing Address - Phone:336-703-4273
Mailing Address - Fax:
Practice Address - Street 1:4555 OGBURN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-2726
Practice Address - Country:US
Practice Address - Phone:336-703-4273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1447381959Medicaid