Provider Demographics
NPI:1912611617
Name:DELISO, ANNIE MCKAY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ANNIE
Middle Name:MCKAY
Last Name:DELISO
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 1:301 PASSAGE WAY APT 3099
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-2998
Mailing Address - Country:US
Mailing Address - Phone:860-951-2629
Mailing Address - Fax:
Practice Address - Street 1:4750 WATERS AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6278
Practice Address - Country:US
Practice Address - Phone:912-350-7412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA11351363A00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty