Provider Demographics
NPI:1487660882
Name:MAZAK, KIM (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:MAZAK
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 1:2106 NEW RD
Mailing Address - Street 2:STE D4
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1046
Mailing Address - Country:US
Mailing Address - Phone:609-926-8899
Mailing Address - Fax:609-653-8713
Practice Address - Street 1:2106 NEW RD
Practice Address - Street 2:STE D4
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1046
Practice Address - Country:US
Practice Address - Phone:609-926-8899
Practice Address - Fax:609-653-8713
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00081100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ080459P5LMedicare ID - Type Unspecified
NJQ18440Medicare UPIN