Healthcare Provider Details

I. General information

NPI: 1497189245
Provider Name (Legal Business Name): DANIEL JOSEPH MIZWICKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 VALENCIA ST
SAN FRANCISCO CA
94110-2405
US

IV. Provider business mailing address

3400 DATA DR ATTN CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 415-432-7889
  • Fax: 415-432-2701
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: