Provider Demographics
NPI:1639251762
Name:MIZACK, KIMBERLY A (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:MIZACK
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 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3530
Mailing Address - Fax:540-776-2036
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3530
Practice Address - Fax:540-776-2036
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1639251762OtherBLACK LUNG
VA1639251762OtherINTOTAL
VA540506332108OtherTRICARE
VA1639251762OtherOPTIMA HEALTH PLAN
VA1639251762OtherMEDICAID QMB
VAP01535314OtherRAILROAD MEDICARE
VA1639251761OtherAETNA
VA1639251762OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA1639251762OtherHUMANA MEDICARE
VAP00803340OtherRAILROAD MEDICARE
VA1639251762OtherANTHEM MEDIGAP
VA1639251762OtherUMWA
VA1639251762OtherUMWA
VA1639251762OtherANTHEM MEDIGAP