Provider Demographics
NPI:1528660826
Name:PANOZZO, ALYSSA (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:PANOZZO
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 1:4291 COVER ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-1980
Mailing Address - Country:US
Mailing Address - Phone:315-256-8088
Mailing Address - Fax:
Practice Address - Street 1:3225 TIMBER FALL CT STE B
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4892
Practice Address - Country:US
Practice Address - Phone:707-442-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1178678363A00000X
MTMED-PAC-LIC-98855363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant