Basic Information
| Provider Information | |||||||||
| NPI: | 1154983757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EZOLT | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172682332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177655088 | ||||||||
| FaxNumber: | 7177655066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2019 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA060824 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103650235 | 05 | PA | MEDICAID | 14497750 | 01 | CAQH | OTHER | MA060824 | 01 | PA | PA LICENSE | OTHER |