Provider Demographics
NPI:1851382121
Name:MISICKO, NANCY E (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:E
Last Name:MISICKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 STONELEA DR
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-7195
Mailing Address - Country:US
Mailing Address - Phone:540-966-1222
Mailing Address - Fax:
Practice Address - Street 1:150 MARKET RIDGE LANE
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083
Practice Address - Country:US
Practice Address - Phone:540-992-4100
Practice Address - Fax:540-992-6669
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5626315Medicaid
VA080178195OtherMEDICARE RAILROAD
VA5623332Medicaid
VA080178195OtherMEDICARE RAILROAD
VA5623332Medicaid