Provider Demographics
NPI:1538715578
Name:ANTZOULATOS, MICAELA DIONYSIOS (PA-C)
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:DIONYSIOS
Last Name:ANTZOULATOS
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 1:2311 DELANEY AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6012
Mailing Address - Country:US
Mailing Address - Phone:910-762-8754
Mailing Address - Fax:910-762-0778
Practice Address - Street 1:2311 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6012
Practice Address - Country:US
Practice Address - Phone:910-762-8754
Practice Address - Fax:910-762-0778
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10240363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC000931038OtherGARDNER-WEBB STUDENT