Provider Demographics
NPI:1104122233
Name:TOMKO, KACEY A (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:A
Last Name:TOMKO
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:KACEY
Other - Middle Name:A
Other - Last Name:HAZELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C,MPAS
Mailing Address - Street 1:340 MONTAGE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1782
Mailing Address - Country:US
Mailing Address - Phone:570-346-3686
Mailing Address - Fax:570-558-6838
Practice Address - Street 1:340 MONTAGE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507
Practice Address - Country:US
Practice Address - Phone:570-346-3686
Practice Address - Fax:570-558-6838
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA802836Medicare PIN