Provider Demographics
NPI:1487922977
Name:KIZA, VESTINE M (PA)
Entity type:Individual
Prefix:
First Name:VESTINE
Middle Name:M
Last Name:KIZA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VESTINE
Other - Middle Name:
Other - Last Name:MUKANSHIMIYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8701 OLD TROY PIKE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1066
Mailing Address - Country:US
Mailing Address - Phone:937-233-7146
Mailing Address - Fax:937-237-4776
Practice Address - Street 1:8701 OLD TROY PIKE
Practice Address - Street 2:SUITE 20
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-1066
Practice Address - Country:US
Practice Address - Phone:937-233-7146
Practice Address - Fax:937-237-4776
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0079695OtherOHIO MEDICAID
OH421534506197OtherCARESOURCE
OH000000804232OtherANTHEM BCBS
OHH073990OtherMEDICARE PTAN