Provider Demographics
NPI:1386002855
Name:CZERWIESKI, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CZERWIESKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7487 TORMES
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6784
Mailing Address - Country:US
Mailing Address - Phone:214-316-7170
Mailing Address - Fax:
Practice Address - Street 1:3301 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2908
Practice Address - Country:US
Practice Address - Phone:817-465-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130138363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily