Provider Demographics
NPI:1982693024
Name:PROENZA, RICHARD M (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:PROENZA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3301 E 1ST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8674
Mailing Address - Country:US
Mailing Address - Phone:912-537-4411
Mailing Address - Fax:912-538-8485
Practice Address - Street 1:3301 E 1ST ST
Practice Address - Street 2:SUITE A
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8674
Practice Address - Country:US
Practice Address - Phone:912-537-4411
Practice Address - Fax:912-538-8485
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA004304363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA954937257EMedicaid
GA954937257FMedicaid
Q11919Medicare UPIN
GA954937257EMedicaid