Provider Demographics
NPI:1497786974
Name:VELAZQUEZ, CARLOS A (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:VELAZQUEZ
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 1:26 LANDERS RD NE
Mailing Address - Street 2:
Mailing Address - City:RYDAL
Mailing Address - State:GA
Mailing Address - Zip Code:30171-1657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2529
Practice Address - Country:US
Practice Address - Phone:706-278-2105
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP35355Medicare UPIN
GA97WCGQFMedicare ID - Type Unspecified