=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639474927
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA REZNIKOVA PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2011
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10910 LITTLE PATUXENT PKWY STE 205
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-3092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-772-0707
-----------------------------------------------------
Fax | 410-772-0707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 YORK ST
-----------------------------------------------------
City | MANITOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54220-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-663-9008
-----------------------------------------------------
Fax | 920-684-1439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | C0004126
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | C0004126
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------