Provider Demographics
NPI:1407306095
Name:POLIZZANO, KIMBERLEY
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:POLIZZANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:484-526-3383
Mailing Address - Fax:484-526-6500
Practice Address - Street 1:1521 8TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-1893
Practice Address - Country:US
Practice Address - Phone:484-526-2598
Practice Address - Fax:484-526-2599
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058543363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA034134OtherMEDICARE GROUP