Provider Demographics
NPI:1194898635
Name:VETZEL, LASHAUN LEE (PA-C)
Entity type:Individual
Prefix:
First Name:LASHAUN
Middle Name:LEE
Last Name:VETZEL
Suffix:
Gender:F
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 1:23 RD MTG
Mailing Address - Street 2:3278 MITCHELL BLVD
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-1459
Mailing Address - Fax:
Practice Address - Street 1:3278 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-5645
Practice Address - Country:US
Practice Address - Phone:229-257-1459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002972363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA970018519OtherRAILROAD MEDICARE
GA1194898635OtherNPI
GA667002OtherBLUE CROSS BLUE SHIELD GA
GA100001360AMedicaid
GA1194898635OtherNPI
GA97WCGDSMedicare ID - Type UnspecifiedPROVIDER ID