Provider Demographics
NPI:1780032524
Name:ZANTELLO, ALYSSA DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:DAWN
Last Name:ZANTELLO
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 1:707 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3409
Mailing Address - Country:US
Mailing Address - Phone:307-578-2000
Mailing Address - Fax:307-578-2010
Practice Address - Street 1:424 YELLOWSTONE AVE STE 120
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9311
Practice Address - Country:US
Practice Address - Phone:307-578-2903
Practice Address - Fax:307-578-2937
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007768363A00000X
WYPA1004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY216670400Medicaid