Provider Demographics
NPI:1104149566
Name:KRISKO, JANICE L (PA)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:L
Last Name:KRISKO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-937-4600
Mailing Address - Fax:440-937-4605
Practice Address - Street 1:1480 CENTER RD
Practice Address - Street 2:SUITE A
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1239
Practice Address - Country:US
Practice Address - Phone:440-937-4600
Practice Address - Fax:440-937-4605
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OHH072820Medicare PIN
OHH190864Medicare PIN
OHH062060Medicare PIN
OH3025372Medicaid
OHH190862Medicare PIN
OHH190863Medicare PIN