Provider Demographics
NPI:1093361974
Name:TAZEWELL, ANN WALLACE (PA)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:WALLACE
Last Name:TAZEWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:10410 RIDGEFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-3500
Mailing Address - Country:US
Mailing Address - Phone:804-754-3776
Mailing Address - Fax:804-754-0880
Practice Address - Street 1:10410 RIDGEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-3500
Practice Address - Country:US
Practice Address - Phone:804-754-3776
Practice Address - Fax:804-754-2365
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110006803363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical