=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770917833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIA VELASQUEZ PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2013
-----------------------------------------------------
Last Update Date | 08/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3675 J DEWEY GRAY CIR STE. 300
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-1868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-863-9595
-----------------------------------------------------
Fax | 706-868-8375
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 15TH ST STE BI1056
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30912-0004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-721-3813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------