1154983757 NPI number — CODY A EZOLT PA-C

Table of content: CODY A EZOLT PA-C (NPI 1154983757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154983757 NPI number — CODY A EZOLT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EZOLT
Provider First Name:
CODY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154983757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
785 5TH AVE STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMBERSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17201-4232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-263-9555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNESBORO
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17268-2332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-765-5088
Provider Business Practice Location Address Fax Number:
717-765-5066
Provider Enumeration Date:
07/03/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MA060824 . This is a "PA LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 103650235 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".