Provider Demographics
NPI:1891708715
Name:MISHKOFSKI, ANNE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:MISHKOFSKI
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 1:225 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1815
Mailing Address - Country:US
Mailing Address - Phone:757-457-5100
Mailing Address - Fax:757-961-3696
Practice Address - Street 1:7185 HARBOUR TOWNE PKWY S STE 200
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3896
Practice Address - Country:US
Practice Address - Phone:757-457-5100
Practice Address - Fax:757-961-3696
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840363363A00000X
GA2359363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7619200754Medicaid
GA7619200754Medicaid
GA202I977203Medicare PIN