Provider Demographics
NPI:1528312295
Name:PRASETIO, SILVYA A (AA)
Entity type:Individual
Prefix:
First Name:SILVYA
Middle Name:A
Last Name:PRASETIO
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 GRAND CENTRAL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-0526
Mailing Address - Country:US
Mailing Address - Phone:912-704-9760
Mailing Address - Fax:
Practice Address - Street 1:5353 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405
Practice Address - Country:US
Practice Address - Phone:912-663-5548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
TX1456367H00000X
GA6620367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant