Provider Demographics
NPI:1598233751
Name:KOLARCZYK, PHILLIP JOSEPH JR (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JOSEPH
Last Name:KOLARCZYK
Suffix:JR
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 1:11910 FOREST MOON DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-3832
Mailing Address - Country:US
Mailing Address - Phone:407-402-1626
Mailing Address - Fax:
Practice Address - Street 1:19073 I 45 S STE 145
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-8744
Practice Address - Country:US
Practice Address - Phone:281-362-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant