Provider Demographics
NPI:1457920076
Name:VIZZA, SHANAE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANAE
Middle Name:
Last Name:VIZZA
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 1:5310 KIETZKE LN STE 104
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2043
Mailing Address - Country:US
Mailing Address - Phone:775-507-4723
Mailing Address - Fax:775-348-8818
Practice Address - Street 1:9990 DOUBLE R BLVD STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-4833
Practice Address - Country:US
Practice Address - Phone:775-348-8800
Practice Address - Fax:775-348-8818
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
COPA.0006863363A00000X
NVPA2563363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1457920076Medicaid
NVV71859OtherMEDICARE NV