Provider Demographics
NPI:1992877120
Name:KASZYCA, JAY (PA)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:KASZYCA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 ELECTRIC AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6575
Mailing Address - Country:US
Mailing Address - Phone:810-982-9911
Mailing Address - Fax:810-985-7740
Practice Address - Street 1:2615 ELECTRIC AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6575
Practice Address - Country:US
Practice Address - Phone:810-982-9911
Practice Address - Fax:810-985-7740
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK004279363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N94810Medicare ID - Type Unspecified
MI0N91790Medicare ID - Type Unspecified
MI0N91780Medicare ID - Type Unspecified