Provider Demographics
NPI:1205174331
Name:ZIZUS, KAALYN ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:KAALYN
Middle Name:ROSE
Last Name:ZIZUS
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 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:46175 WESTLAKE DRIVE, SUITE 120
Practice Address - Street 2:
Practice Address - City:POTOMAC FALLS
Practice Address - State:VA
Practice Address - Zip Code:20165-5873
Practice Address - Country:US
Practice Address - Phone:703-444-0100
Practice Address - Fax:703-444-7600
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004109363A00000X
CAPA57660363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205174331Medicaid
VA30015891910003Medicaid