Provider Demographics
NPI:1205842077
Name:KOZLOWSKI, JOSPEH W (PA)
Entity Type:Individual
Prefix:
First Name:JOSPEH
Middle Name:W
Last Name:KOZLOWSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVE
Mailing Address - Street 2:BOX 232
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3001
Mailing Address - Country:US
Mailing Address - Phone:585-922-3784
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:BOX 232
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP29564Medicare UPIN