Provider Demographics
NPI:1295332005
Name:KSANZNAK, ADAM MICHAEL (DPT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:MICHAEL
Last Name:KSANZNAK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 744113
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-4113
Mailing Address - Country:US
Mailing Address - Phone:703-239-2300
Mailing Address - Fax:
Practice Address - Street 1:5900 E VIRGINIA BEACH BLVD STE 21
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2499
Practice Address - Country:US
Practice Address - Phone:757-995-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist