Basic Information
| Provider Information | |||||||||
| NPI: | 1801487293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMAFIDON | ||||||||
| FirstName: | SUNDAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 S 8TH ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | GRIFFIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302244260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702296072 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 619 S 8TH ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | GRIFFIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302244260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702296072 | ||||||||
| FaxNumber: | 7702292111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2021 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN230604 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.