Provider Demographics
NPI:1164968434
Name:MIZGALA, JONATHAN (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MIZGALA
Suffix:
Gender:M
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14614-1134
Mailing Address - Country:US
Mailing Address - Phone:585-325-2280
Mailing Address - Fax:
Practice Address - Street 1:55 CENTRAL PLZ STE B
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-1753
Practice Address - Country:US
Practice Address - Phone:315-444-1900
Practice Address - Fax:315-363-2549
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405393363LP0808X
NYF342409363L00000X
NY342409363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05296391Medicaid