Provider Demographics
NPI:1417647579
Name:WICZYNSKI, TERESA L (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:WICZYNSKI
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 1:2933 BRECKENRIDGE LN STE 103
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1494
Mailing Address - Country:US
Mailing Address - Phone:502-394-5678
Mailing Address - Fax:
Practice Address - Street 1:2933 BRECKENRIDGE LN STE 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1494
Practice Address - Country:US
Practice Address - Phone:502-394-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC400363A00000X
390200000X
KYPA3248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program