Provider Demographics
NPI:1639474927
Name:REZNIKOVA, ANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:REZNIKOVA
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:10910 LITTLE PATUXENT PKWY STE 205
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3092
Practice Address - Country:US
Practice Address - Phone:410-772-0707
Practice Address - Fax:410-772-0707
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004126363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD567073YWV2Medicare PIN
MD234950ZDDBMedicare PIN
MD234950YVZMedicare PIN