Provider Demographics
NPI:1609686112
Name:GALICIA, CAROL BURZON (PA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:BURZON
Last Name:GALICIA
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:3919 W JEFFERSON BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6811
Mailing Address - Country:US
Mailing Address - Phone:260-436-7722
Mailing Address - Fax:260-459-0012
Practice Address - Street 1:3919 W JEFFERSON BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6811
Practice Address - Country:US
Practice Address - Phone:260-436-7722
Practice Address - Fax:260-459-0012
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10004703A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant