Provider Demographics
NPI:1649377961
Name:IVANSEK, NANCY (PA-C,MA)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:IVANSEK
Suffix:
Gender:F
Credentials:PA-C,MA
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 537
Mailing Address - Street 2:
Mailing Address - City:NEWBURY
Mailing Address - State:OH
Mailing Address - Zip Code:44065-0537
Mailing Address - Country:US
Mailing Address - Phone:440-564-5656
Mailing Address - Fax:440-564-5719
Practice Address - Street 1:10780 KINSMAN RD
Practice Address - Street 2:
Practice Address - City:NEWBURY
Practice Address - State:OH
Practice Address - Zip Code:44065-0537
Practice Address - Country:US
Practice Address - Phone:440-564-5656
Practice Address - Fax:440-564-5719
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000392363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS65840Medicare UPIN
OHPA12494Medicare PIN