Provider Demographics
NPI:1982878609
Name:VIZZACCARO, AUDREY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:VIZZACCARO
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 1:1261 SOUTH LAPEER RD
Mailing Address - Street 2:STE 201
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360
Mailing Address - Country:US
Mailing Address - Phone:248-814-7546
Mailing Address - Fax:248-814-8900
Practice Address - Street 1:1261 SOUTH LAPEER RD
Practice Address - Street 2:STE 201
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360
Practice Address - Country:US
Practice Address - Phone:248-814-7546
Practice Address - Fax:248-814-8900
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003044363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical