Provider Demographics
NPI:1225409485
Name:DECKER, ANTONIA MARIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:ANTONIA
Middle Name:MARIE
Last Name:DECKER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:ANTONIA
Other - Middle Name:M
Other - Last Name:GARLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4325 LAKE BOONE TRL STE 315
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7510
Mailing Address - Country:US
Mailing Address - Phone:849-974-0496
Mailing Address - Fax:
Practice Address - Street 1:4325 LAKE BOONE TRL STE 315
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7510
Practice Address - Country:US
Practice Address - Phone:984-974-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3951363A00000X
IL085.005534363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1225409485Medicaid
WIK400369833Medicare PIN