Provider Demographics
NPI:1780847699
Name:EZZELL, TREVOR FREDERICK (FNP)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:FREDERICK
Last Name:EZZELL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:655 JESSE JEWELL PKWY SE
Practice Address - Street 2:STE B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3854
Practice Address - Country:US
Practice Address - Phone:770-532-7092
Practice Address - Fax:770-536-0383
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN152048363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA462656OtherWELLCARE
GA01228809OtherAMERIGROUP
GA129681407AMedicaid
GAP00903614OtherMEDICARE RAILROAD
GA129681407BMedicaid
GA129681407CMedicaid
GA129681407CMedicaid