Healthcare Provider Details

I. General information

NPI: 1770917833
Provider Name (Legal Business Name): MELANIA VELASQUEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 J DEWEY GRAY CIR STE. 300
AUGUSTA GA
30909-1868
US

IV. Provider business mailing address

1120 15TH ST STE BI1056
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9595
  • Fax: 706-868-8375
Mailing address:
  • Phone: 706-721-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: