Provider Demographics
NPI:1881138576
Name:WITCZAK, KATHRYN ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:WITCZAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 TAYLOR LN
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4540
Mailing Address - Country:US
Mailing Address - Phone:862-222-4285
Mailing Address - Fax:
Practice Address - Street 1:1825 RTE 35
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3541
Practice Address - Country:US
Practice Address - Phone:732-280-2600
Practice Address - Fax:848-469-8933
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00420800363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0542474Medicaid