Healthcare Provider Details

I. General information

NPI: 1043808801
Provider Name (Legal Business Name): ANTHONY PAUL CAMPANELLA PA - C, CAQ-PSYCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 WINN WAY STE 221
DECATUR GA
30030-1723
US

IV. Provider business mailing address

183 MORELAND AVE SE UNIT 103
ATLANTA GA
30316-1338
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-8995
  • Fax:
Mailing address:
  • Phone: 386-882-7323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: