Healthcare Provider Details

I. General information

NPI: 1770650467
Provider Name (Legal Business Name): ELIZABETH GRACE YRIZARRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

3405 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

V. Phone/Fax

Practice location:
  • Phone: 706-792-7021
  • Fax:
Mailing address:
  • Phone: 706-792-7021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001947
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: