Provider Demographics
NPI:1932153277
Name:KAZIK, JACQUELINE (PAC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:KAZIK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:PLANK ROAD CLINIC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PLANK ROAD CLINIC
Practice Address - Street 2:1155 NORTH MAYFAIR ROAD
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-456-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI434-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42916700Medicaid
003000261NOtherHUMANA
0005C73601Medicare ID - Type Unspecified
WI007068150Medicare PIN
R97791Medicare UPIN