Healthcare Provider Details

I. General information

NPI: 1295332005
Provider Name (Legal Business Name): ADAM MICHAEL KSANZNAK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 E VIRGINIA BEACH BLVD STE 21
NORFOLK VA
23502-2499
US

IV. Provider business mailing address

PO BOX 744113
ATLANTA GA
30384-4113
US

V. Phone/Fax

Practice location:
  • Phone: 757-995-1903
  • Fax:
Mailing address:
  • Phone: 703-239-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305213848
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: