Provider Demographics
NPI:1073568747
Name:AZZARELLO, ANTHONY A (PA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:A
Last Name:AZZARELLO
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX BOX 864074
Mailing Address - Street 2:HALIFAX HEALTHCARE SYSTEMS, INC.
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-4074
Mailing Address - Country:US
Mailing Address - Phone:386-226-4590
Mailing Address - Fax:386-226-3371
Practice Address - Street 1:303 NO. CLYDE MORRIS BLVD.
Practice Address - Street 2:HALIFAX MEDICAL CENTER - CHEST PAIN CENTER
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-425-1800
Practice Address - Fax:386-425-1804
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9103151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292228200Medicaid
Q50912Medicare UPIN
FLU5720VMedicare PIN