Provider Demographics
NPI:1689756520
Name:KANCIANIC, RACHEL LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:LOUISE
Last Name:KANCIANIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:RACHEL
Other - Middle Name:LOUISE
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-594-2195
Practice Address - Street 1:30 SHADY LANE
Practice Address - Street 2:
Practice Address - City:WHITE STONE
Practice Address - State:VA
Practice Address - Zip Code:22578-0046
Practice Address - Country:US
Practice Address - Phone:804-435-3133
Practice Address - Fax:804-435-1311
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-002418363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q77357Medicare UPIN
VAP00616659Medicare PIN
VA017644R53Medicare PIN