Provider Demographics
NPI:1023619129
Name:VONCK, ANNA LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:LEIGH
Last Name:VONCK
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 1:6300 HOSPITAL PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1829
Mailing Address - Country:US
Mailing Address - Phone:770-771-6591
Mailing Address - Fax:
Practice Address - Street 1:6300 HOSPITAL PKWY STE 100
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-1829
Practice Address - Country:US
Practice Address - Phone:707-716-5917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025874363A00000X
GA11341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025874OtherOFFICE OF THE PROFESSIONS LICENSURE/REGISTRATION NUMBER
1177899OtherNCCPA CERTIFICATION NUMBER