Provider Demographics
NPI:1639313554
Name:FERGUSON, CAROLYN ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:ANN
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:ANN
Other - Last Name:ZAWISTOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:75 E STREET RD
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6047
Practice Address - Country:US
Practice Address - Phone:267-684-1047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055688363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMZ2782743OtherDEA