Provider Demographics
NPI:1851133862
Name:KIZZIAR, ETHAN (DPT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:KIZZIAR
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7845 WESTSIDE DR APT 427
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1261
Mailing Address - Country:US
Mailing Address - Phone:503-575-0648
Mailing Address - Fax:
Practice Address - Street 1:120 C AVE STE 110
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1992
Practice Address - Country:US
Practice Address - Phone:858-225-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist