Provider Demographics
NPI:1710371091
Name:PROVENZANO, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 PALADIN DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7826
Mailing Address - Country:US
Mailing Address - Phone:252-752-8880
Mailing Address - Fax:252-317-2092
Practice Address - Street 1:511 PALADIN DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7826
Practice Address - Country:US
Practice Address - Phone:252-752-8880
Practice Address - Fax:252-317-2092
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-01052207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology