Provider Demographics
NPI:1194004523
Name:KOZAK, ELIZABETH ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name:KOZAK
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 1:15474 N HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4893
Mailing Address - Country:US
Mailing Address - Phone:734-335-6103
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:15474 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4893
Practice Address - Country:US
Practice Address - Phone:734-335-6103
Practice Address - Fax:630-734-4715
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004076363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5695046Medicare PIN