MEDICARE: RICHARD M PROENZA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	004304	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982693024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD M PROENZA PA-C

Provider Business Mailing Address
First Line	:	3301 E 1ST ST
Second Line	:	SUITE A
City	:	VIDALIA
State	:	GA
Zip	:	30474-8674
Country	:	US
Telephone Number	:	912-537-4411
Fax Number	:	912-538-8485

Provider Business Practice Location Address
First Line	:	3301 E 1ST ST
Second Line	:	SUITE A
City	:	VIDALIA
State	:	GA
Zip	:	30474-8674
Country	:	US
Telephone Number	:	912-537-4411
Fax Number	:	912-538-8485

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	10/03/2013

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Directions to “ RICHARD M PROENZA PA-C” Practice Location

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