Provider Demographics
NPI:1326537853
Name:WITCZAK, VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:WITCZAK
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 1:800 WASHINGTON ST
Mailing Address - Street 2:PO BOX 1013: PROVIDER ENROLLMENT
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-8153
Mailing Address - Fax:617-636-1465
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-7846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6481363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110139890AMedicaid