Basic Information
| Provider Information | |||||||||
| NPI: | 1851382121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISICKO | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 STONELEA DR | ||||||||
| Address2: | |||||||||
| City: | TROUTVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241757195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409661222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 MARKET RIDGE LANE | ||||||||
| Address2: | |||||||||
| City: | DALEVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409924100 | ||||||||
| FaxNumber: | 5409926669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101231419 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5626315 | 05 | VA | MEDICAID | 080178195 | 01 | VA | MEDICARE RAILROAD | OTHER | 5623332 | 05 | VA | MEDICAID |