Provider Demographics
NPI:1811965312
Name:RIZVANOVIC, VESNA (PA)
Entity type:Individual
Prefix:
First Name:VESNA
Middle Name:
Last Name:RIZVANOVIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 LANIER PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2059
Mailing Address - Country:US
Mailing Address - Phone:678-450-0202
Mailing Address - Fax:678-450-0080
Practice Address - Street 1:663 LANIER PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2059
Practice Address - Country:US
Practice Address - Phone:678-450-0202
Practice Address - Fax:678-450-0080
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004603363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA684796932BMedicaid
GA684796932BMedicaid
GA202I971374Medicare PIN