Provider Demographics
NPI:1952800203
Name:KUMISKI, MAXX A (PA)
Entity type:Individual
Prefix:
First Name:MAXX
Middle Name:A
Last Name:KUMISKI
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-5910
Practice Address - Country:US
Practice Address - Phone:415-746-1812
Practice Address - Fax:415-829-2326
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2020-02-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT4082363A00000X
CA57698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant