Provider Demographics
NPI:1578044590
Name:CIZMOWSKI, MYLINDA
Entity Type:Individual
Prefix:
First Name:MYLINDA
Middle Name:
Last Name:CIZMOWSKI
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 1:575 RIVERSTONE WAY UNIT 1
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2939
Mailing Address - Country:US
Mailing Address - Phone:907-450-3300
Mailing Address - Fax:
Practice Address - Street 1:575 RIVERSTONE WAY UNIT 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-2939
Practice Address - Country:US
Practice Address - Phone:907-450-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK149997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program