Basic Information
| Provider Information | |||||||||
| NPI: | 1891708715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISHKOFSKI | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CLEARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574575100 | ||||||||
| FaxNumber: | 7579613696 | ||||||||
| Practice Location | |||||||||
| Address1: | 7185 HARBOUR TOWNE PKWY S STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234353896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574575100 | ||||||||
| FaxNumber: | 7579613696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110840363 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 2359 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 7619200754 | 05 | GA | MEDICAID |