Provider Demographics
NPI:1659867711
Name:DALZELL, ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:DALZELL
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 1:1026 CALIBRE SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1879
Mailing Address - Country:US
Mailing Address - Phone:305-527-8841
Mailing Address - Fax:
Practice Address - Street 1:882 PONCE DE LEON AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4268
Practice Address - Country:US
Practice Address - Phone:708-093-0347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022090363A00000X
GA11005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant