Healthcare Provider Details

I. General information

NPI: 1619244696
Provider Name (Legal Business Name): DEVON T KSIAZK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEVON T RUEN PA

II. Dates (important events)

Enumeration Date: 11/19/2011
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ALTAIR PKWY STE 3200
WESTERVILLE OH
43082-7653
US

IV. Provider business mailing address

7281 SAWMILL ROAD SUITE 100
DUBLIN OH
43016
US

V. Phone/Fax

Practice location:
  • Phone: 614-392-5160
  • Fax: 614-764-1707
Mailing address:
  • Phone: 614-764-0707
  • Fax: 614-764-1707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003412
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: