Provider Demographics
NPI:1538662937
Name:VISCOGLIOSI, PAUL (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:VISCOGLIOSI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 CHRIS ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-8631
Mailing Address - Country:US
Mailing Address - Phone:925-381-3790
Mailing Address - Fax:
Practice Address - Street 1:3883 AIRWAY DR STE 165
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1675
Practice Address - Country:US
Practice Address - Phone:707-521-7799
Practice Address - Fax:707-573-5431
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55373363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical