Provider Demographics
NPI:1508424953
Name:KOTOWSKI, BRETT ALLEN (AGPCNP)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:ALLEN
Last Name:KOTOWSKI
Suffix:
Gender:M
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 RIDGEBROOK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPARKS GLENCOE
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9477
Mailing Address - Country:US
Mailing Address - Phone:443-483-9300
Mailing Address - Fax:
Practice Address - Street 1:2010 N CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1222
Practice Address - Country:US
Practice Address - Phone:317-924-5821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN28230200A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program