Provider Demographics
NPI:1073172003
Name:KOWSARI, ABOLFAZL (CNP)
Entity Type:Individual
Prefix:MR
First Name:ABOLFAZL
Middle Name:
Last Name:KOWSARI
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:MR
Other - First Name:FAZY
Other - Middle Name:
Other - Last Name:KOWSARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:9512 PINEVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7135
Mailing Address - Country:US
Mailing Address - Phone:763-923-5608
Mailing Address - Fax:
Practice Address - Street 1:9512 PINEVIEW LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7135
Practice Address - Country:US
Practice Address - Phone:763-923-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6617363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily