Individual
RICHARD M PROENZA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3301 E 1ST ST, SUITE A, VIDALIA, GA 30474-8674
(912) 537-4411
(912) 538-8485
Mailing address
3301 E 1ST ST, SUITE A, VIDALIA, GA 30474-8674
(912) 537-4411
(912) 538-8485
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
004304
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
954937257E
—
GA
05
—
954937257F
—
GA
Enumeration date
10/20/2005
Last updated
10/03/2013
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