Basic Information
| Provider Information | |||||||||
| NPI: | 1285648600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALAZZO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14039 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309190039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639797 | ||||||||
| FaxNumber: | 7068607686 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 J DEWEY GRAY CIR | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309091867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639797 | ||||||||
| FaxNumber: | 7068607686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003708 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00398077 | 01 | GA | RAILROAD MEDICARE | OTHER | 100000220C | 05 | GA | MEDICAID |