Individual
KIMBERLY A MIZACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
1802 BRAEBURN DR, SALEM, VA 24153-7357
(540) 772-3530
(540) 776-2036
Mailing address
1802 BRAEBURN DR, SALEM, VA 24153-7357
(540) 772-3530
(540) 776-2036
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0110002410
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1639251761
AETNA
VA
01
—
1639251762
BLACK LUNG
VA
01
—
540506332108
TRICARE
VA
01
—
P00803340
RAILROAD MEDICARE
VA
01
—
P01535314
RAILROAD MEDICARE
VA
Enumeration date
10/19/2006
Last updated
02/10/2022
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