Provider Demographics
NPI:1225312382
Name:KOZLOFF, JOSEPHINE WIDJAJA (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:WIDJAJA
Last Name:KOZLOFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6002 DIAMOND RUBY STE 3-125
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00820-5226
Mailing Address - Country:US
Mailing Address - Phone:340-998-2404
Mailing Address - Fax:340-713-7272
Practice Address - Street 1:6040 CASTLE COAKLEY
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820-5343
Practice Address - Country:US
Practice Address - Phone:340-998-2404
Practice Address - Fax:340-713-7272
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21803363A00000X
VI048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant