Provider Demographics
NPI:1184819807
Name:DEFAZIO, WILLIAM ELWOOD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ELWOOD
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 NORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3361
Mailing Address - Country:US
Mailing Address - Phone:916-929-8575
Mailing Address - Fax:
Practice Address - Street 1:3911 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3361
Practice Address - Country:US
Practice Address - Phone:916-929-8575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19321363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical