Provider Demographics
NPI:1427598119
Name:KOWALCYK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KOWALCYK
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 1:9612 SE HIGHBORNE WAY
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-6828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9612 SE HIGHBORNE WAY
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-6828
Practice Address - Country:US
Practice Address - Phone:561-529-0322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9335901367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered