Provider Demographics
NPI:1184754012
Name:NISCHIK, KIMBERLY D (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:NISCHIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:PROHASKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:580 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4407
Mailing Address - Country:US
Mailing Address - Phone:775-786-4673
Mailing Address - Fax:775-348-2889
Practice Address - Street 1:580 W 5TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4407
Practice Address - Country:US
Practice Address - Phone:775-786-4673
Practice Address - Fax:775-348-2889
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00388541OtherRAILROAD MEDICARE
NVQ78629Medicare UPIN
V103751Medicare PIN