Provider Demographics
NPI:1639185333
Name:EZZELL, LONNA ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:LONNA
Middle Name:ELAINE
Last Name:EZZELL
Suffix:
Gender:F
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 1:5323 ARGYLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5812
Mailing Address - Country:US
Mailing Address - Phone:210-844-6049
Mailing Address - Fax:
Practice Address - Street 1:527 LOGWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-1738
Practice Address - Country:US
Practice Address - Phone:210-588-6774
Practice Address - Fax:210-588-6305
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB117605Medicare PIN