Provider Demographics
NPI:1609245364
Name:KORKOWSKI, PHILLIP (RN)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:KORKOWSKI
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-4039
Mailing Address - Country:US
Mailing Address - Phone:651-774-0202
Mailing Address - Fax:651-774-5517
Practice Address - Street 1:317 YORK AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4039
Practice Address - Country:US
Practice Address - Phone:651-774-0202
Practice Address - Fax:651-774-5517
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 97432-7103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical