Healthcare Provider Details

I. General information

NPI: 1225893720
Provider Name (Legal Business Name): GANNA KOZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 04/06/2025
Certification Date: 04/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9912 CAMBERLY CT
GRANITE BAY CA
95746-6653
US

IV. Provider business mailing address

9912 CAMBERLY CT
GRANITE BAY CA
95746-6653
US

V. Phone/Fax

Practice location:
  • Phone: 916-582-8533
  • Fax:
Mailing address:
  • Phone: 916-582-8533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65668
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: