Provider Demographics
NPI:1699913061
Name:LUSZCZYK, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LUSZCZYK
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 1:2322 E KIMBERLY RD
Mailing Address - Street 2:STE 100N
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7205
Mailing Address - Country:US
Mailing Address - Phone:563-355-3376
Mailing Address - Fax:
Practice Address - Street 1:2322 E KIMBERLY RD
Practice Address - Street 2:STE 100N
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7205
Practice Address - Country:US
Practice Address - Phone:563-355-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002199363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical