Provider Demographics
NPI:1750661765
Name:DORONILA, HAZEL ANN M (PA)
Entity Type:Individual
Prefix:
First Name:HAZEL ANN
Middle Name:M
Last Name:DORONILA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 BLUE RIDGE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6477
Mailing Address - Country:US
Mailing Address - Phone:919-784-7110
Mailing Address - Fax:919-784-7111
Practice Address - Street 1:2800 BLUE RIDGE RD STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6477
Practice Address - Country:US
Practice Address - Phone:919-784-7110
Practice Address - Fax:919-784-7111
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015026363AS0400X
NC0010-06898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03580169Medicaid
NYP01218526OtherRAIL ROAD MEDICARE
NYJ400086012OtherMEDICARE PTAN