Provider Demographics
NPI:1154983757
Name:EZOLT, CODY A (PA-C)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:A
Last Name:EZOLT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 5TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:
Practice Address - Street 1:601 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268-2332
Practice Address - Country:US
Practice Address - Phone:717-765-5088
Practice Address - Fax:717-765-5066
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA060824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103650235Medicaid
14497750OtherCAQH
PAMA060824OtherPA LICENSE