Provider Demographics
NPI:1326058165
Name:NIZNIK, REBECCA HENDERSON (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:HENDERSON
Last Name:NIZNIK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-2403
Mailing Address - Fax:970-490-4173
Practice Address - Street 1:595 CHAPEL HILLS DR STE 302
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1057
Practice Address - Country:US
Practice Address - Phone:719-364-4141
Practice Address - Fax:719-364-4140
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1644363AM0700X
COPA.0001644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50676334Medicaid
CO50676334Medicaid
490528Medicare ID - Type Unspecified