Healthcare Provider Details

I. General information

NPI: 1205174331
Provider Name (Legal Business Name): KAALYN ROSE ZIZUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2013
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46175 WESTLAKE DRIVE, SUITE 120
POTOMAC FALLS VA
20165-5873
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-444-0100
  • Fax: 703-444-7600
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004109
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: