Provider Demographics
NPI:1417321894
Name:KOLSKI, TREVOR ALLEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:ALLEN
Last Name:KOLSKI
Suffix:
Gender:M
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:PO BOX 936535
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1995 E OAKLAND PARK BLVD STE 310
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1138
Practice Address - Country:US
Practice Address - Phone:954-791-6146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-22
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109130363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLXZSJCOtherFLORIDA BLUE CROSS BLUE SHIELD
FL107820200Medicaid